Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review

The Work-life Check-ins randomized controlled trial: A leader-based adaptive, semi-structured burnout intervention in primary care clinics

BACKGROUND

Burnout in primary care undermines worker well-being and patient care. Many factors contribute to burnout, including high workloads, emotional stress, and unsupportive supervisors. Formative evidence suggests that burnout might be reduced if clinic leaders hold quarterly and brief (∼30 min) one-on-one check-ins with team members to acknowledge and address work-life stressors (e.g., schedules, workflow breakdowns, time off requests). This paper describes the intervention protocol for a randomized controlled trial (RCT) designed to evaluate the effectiveness and process of the check-ins in reducing burnout among primary care professionals.

METHODS

Two-arm RCT conducted at 12 primary care clinics of a healthcare system in the Pacific Northwest. Six clinics received an adaptive design, semi-structured intervention, including predefined training modules with evidence-based tactics to reduce burnout through the check-ins, followed by clinic-specific feedback sessions prior to offering and conducting quarterly leader-employee check-ins. Six clinics were randomized as waitlist controls. Burnout was measured using the Maslach Burnout Inventory (MBI) at baseline and at the 12-month follow-up. Secondary outcomes include organizational constraints, psychological safety, and supervisor support. Multilevel modeling and qualitative methods were applied to evaluate the effects and process of the intervention.

CONCLUSION

By focusing on modifiable work-life factors such as stressors and supervisor support, the check-ins intervention aims to reduce burnout rates among primary care professionals. Findings from this trial will shed light on the conditions upon which check-ins might reduce burnout. Results will also inform policies and interventions aimed at improving mental health and well-being in primary care settings.

CLINICALTRIALS

gov: ID NCT05436548.

E-learning-an interventional element of the PRiVENT project to improve weaning expertise

BACKGROUND

PRiVENT (PRevention of invasive VENTilation) is an evaluation of a bundle of interventions aimed at the prevention of long-term invasive mechanical ventilation. One of these elements is an e-learning course for healthcare professionals to improve weaning expertise. The aim of our analysis is to examine the implementation of the course in cooperating intensive care units.

METHODS

The course has been developed through a peer review process by pulmonary and critical care physicians in collaboration with respiratory therapists, supported by health services researchers and a professional e-learning agency. The e-learning platform "weLearn" was made available online to participating healthcare professionals. Feedback on the e-learning programme was obtained and discussed in quality circles (QCs). We measured the acceptance and use of the programme through access statistics.

RESULTS

The e-learning course "Joint Prevention of Long-Term Ventilation" consists of 7 separate modules with practice-oriented training units as well as a cross-module area and corresponding interactive case studies. Users can receive 23 CME (continuing medical education) credits. The platform was released on July 1, 2021. By June 28, 2023, 214 users from 33 clinics had registered. Most users (77-98%) completed the modules, thus performing well in the test, where 90-100% passed. In the QCs, the users commended the structure and practical relevance of the programme, as well as the opportunity to earn CME credits.

CONCLUSION

Especially for medical staff in intensive care units, where continuous training is often a challenge during shift work, e-learning is a useful supplement to existing medical training.

TRIAL REGISTRATION

The PRiVENT study is registered at ClinicalTrials.gov (NCT05260853) on 02/03/2022.

Using Implementation Mapping to develop an intervention program to support veterinarians' adherence to the guideline on Streptococcus suis clinical practice in weaned pigs

Streptococcus suis (S. suis) infections in weaned pigs are common and responsible for a high consumption of antimicrobials, and their presence is assumed to be multi-factorial. A specific evidence-based veterinary guideline to support the control of S. suis in weaned pigs was developed for veterinary practitioners in the Netherlands in 2014. Adherence to the S. suis clinical practice guideline helps veterinary practitioners to prevent and control the disease in a systematical approach and thereby improve antimicrobial stewardship and contribute to the prevention of antimicrobial resistance in animals and humans. The impact of such a clinical practice guideline on (animal) disease management depends not only on its content, but also largely on the extent to which practitioners adhere to the clinical guideline in practice. When the S. suis guideline was published, no specific activities were undertaken to support veterinarians' uptake and implementation, thereby contributing to suboptimal adherence in clinical practice. As the S. suis guideline was comprehensively written by veterinary experts following an evidence-based approach, our aim was not to judge the (scientific) quality of the guideline but to study the possibility to improve the currently low adherence of this guideline in veterinary practice. This paper describes the systematic development, using Implementation Mapping, of a theory-based intervention program to support swine veterinarians' adherence to the S. suis guideline. The knowledge, skills, beliefs about capabilities, and beliefs about consequences domains are addressed in the program, which includes seven evidence-based methods (modelling, tailoring, feedback, discussion, persuasive communication, active learning, and self-monitoring) for use in program activities such as a peer-learning meeting and an e-learning module. The intervention program has been developed for practicing swine veterinarians, lasts eight months, and is evaluated through a stepped-wedge design. The Implementation Mapping approach ensured that all relevant adopters and implementers were involved, and that outcomes, determinants (influencing factors), and objectives were systematically discussed.

'Change talk' among physicians in small group learning communities: An ethnographic study

INTRODUCTION

Physicians face uncertainties in complex clinical environments. Small group learning initiatives allow physicians to decipher new evidence and address challenges. This study aimed to understand how physicians in small learning groups discuss, interpret and assess new evidence-based information to make decisions for practice.

METHODS

An ethnographic approach was used to collect data from observed discussions between practising family physicians (n = 15) that meet in small learning groups (n = 2). Physicians were members of a continuing professional development (CPD) programme that provides educational modules with clinical cases and evidence-based recommendations for best practice. Nine learning sessions were observed over 1 year. Field notes documenting the conversations were analysed using ethnographic observational dimensions and thematic content analysis. Observational data were supplemented with interviews (n = 9) and practice reflection documents (n = 7). A conceptual framework for 'change talk' was created.

RESULTS

Observations elucidated the following: Facilitators played a significant role in leading the discussion by focusing on practice gaps. As group members shared approaches to clinical cases, baseline knowledge and practice experiences were revealed. Members made sense of new information by asking questions and sharing knowledge. They determined what information was useful and whether it applied to their practice. They reviewed evidence, tested algorithms, benchmarked themselves to best practice and consolidated knowledge before committing to practice change(s). Themes from interviews emphasised that sharing of practice experiences played an integral part in decisions to implement new knowledge, helped validate guideline recommendations and provided strategies for feasible practice changes. Documented practice reflections regarding decisions for practice change(s) overlapped with field notes.

CONCLUSION

This study provides empirical data on how small groups of family physicians discuss evidence-based information and make decisions for clinical practice. A 'change talk' framework was created to illustrate the processes that occur when physicians interpret and assess new information to bridge gaps between current and best practices.

From purists to pragmatists: a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19

BACKGROUND

Despite progress, maternal and neonatal mortality and still births remain high in South Africa. The South African National Department of Health implemented a quality improvement (QI) programme, called Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health facilities, seven per participating province, between 2018 and 2022.

METHODS

We conducted a qualitative process evaluation of the contextual and implementation process factors' influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection included three interview rounds with the leaders and members of the QI teams in each facility; intermittent interviews with the QI advisors; programme documentation review; observation of programme management meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake varied across the three provinces and between facilities within provinces.

RESULTS

Between March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected QI teams in one province more severely than others, because they received limited pre-pandemic training. Better uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders' intrinsic motivation to apply QI methodology. We found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19. Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not the prescribed tools.

CONCLUSIONS

Our study underscores the critical role of intrinsic motivation of team leaders, support from experienced technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps cannot be followed.

A quality control circle process to improve enteral nutrition feeding support in discharged patients with colorectal cancer

Correct usage and maintenance of the enteral nutrition feeding pump system is always a challenge in nutrition support for patients with colorectal cancer (CRC). However, there are few studies on the sustained accuracy improvement of the enteral nutrition feeding system in discharged CRC patients. Here, we established a seven-month quality control circle (QCC) activity with the theme of improving the performance of home enteral feeding pumps (EFP) and examined the effect of QCC activity on the nutritional state and quality of life in discharged CRC patients. We enrolled 100 discharged CRC patients treated with home enteral nutrition from Zhejiang Cancer Hospital between March 2020 and December 2021. The patients were randomly split into two research groups: one participated in the QCC activity (n = 50) and the other did not (n = 50). QCC analysis indicated that the top 3 causes of EFP inaccurate usage are the simple and boring contents of training, various types of pumps, no examination rules, and lack of management. Furthermore, both intra- and inter-group comparisons showed that QCC significantly improved the patients' pass rate of nutrition pump operation from 52 to 70% after 1-month of activity, which gradually improved and got the highest (90%) after 3 months (p < 0.05). Interestingly, the established QCC activity significantly increased the patient-generated subjective global assessment (PG-SGA) and Barthel index (BI) scores, body fat mass (BFM) and superior longitudinal muscle (SLM) by intra- and inter-group comparisons. In this study, we clarified the main causes of inaccurate EFP usage and established a QCC process to improve the pass rate of EFP usage. It finally leads to the improvement of nutritional state and quality of life in CRC patients.

Will the implementation process for goal-oriented primary care succeed? A qualitative study investigating five perceived attributes of goal-oriented care

Throughout the western world, goal oriented care (GOC) is increasingly promoted as a strategy towards more person-centered, integrated care. The implementation of goal-oriented care not only takes place at the micro-level with individual primary care providers (PCPs) changing their approach, but also requires meso- and macro-level investment. In this study, we zoom in on experiences and actions of various meso- and macro-level actors that are actively engaged with implementing GOC, both within their organization or at the policy level. In-depth interviews were conducted with n = 23 actors from a variety of different organizations (governmental institutions, provider organizations, patient organizations, health/social care organizations, primary care zones/care councils, etc.), using a semi- interview guide inspired by realist interviewing. Three main drivers for implementation were identified: recognition, commitment and coordination. On top of that, results were interpreted through Rogers' Diffusion of Innovations (Dol) theory in which five attributes are discussed that contribute to or hinder implementation success. Our findings can help define actions to support and facilitate the implementation process of an innovation such as GOC.

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Changes in BMD T-score from pre-to post-treatment with biosimilar teriparatide: A single-arm, multi-center study

Introduction

Teriparatide is a recombinant analog of the parathyroid hormone and an anabolic treatment modality for osteoporosis. This study aimed to evaluate the effectiveness of biosimilar teriparatide (CinnoPar®, CinnaGen Co., Iran) in osteoporotic patients after at least one year of treatment.

Methods

In this multi-center, single-arm study, 239 eligible patients received subcutaneous injections of biosimilar teriparatide 20 μg once daily for at least one year. The main outcome measure was the change in bone mineral density (BMD) T-score from baseline (pre-treatment) to end of the study (post-treatment). In addition, the change in the fracture risk assessment tool (FRAX) score was calculated to estimate the 10-year probability of major and hip fractures pre-and post-treatment.

Results

A total of 239 patients (age, 63 ± 12.14 years; female, 88.28 %) were included, of which 27.62 % (66/239), 14.64 % (35/239), and 57.74 % (138/239) received biosimilar teriparatide for 12-16 months, 17-20 months, and 21-24 months, respectively. From baseline to end of the study, the T-score at the lumbar spine increased from -2.67 ± 1.04 to -2.26 ± 1.11 (mean percent change, 13.07 ± 62.89; p-value<0.001). Similarly, the T-score at femoral neck increased from -2.18 ± 0.87 to -2.09 ± 0.93 (mean percent change, 3.81 ± 31.52; p-value = 0.006). The proportions of patients with maintained or improved BMD T-score at the lumbar spine and femoral neck sites were 85.36 % (204/239) and 69.04 % (165/239), respectively. Similar results were obtained in subgroups of patients with rheumatoid arthritis and those with a history of a previous fracture or parental hip fracture. FRAX scores did not change significantly during the study (p-values of 0.551 and 0.973 at the lumbar spine and femoral neck, respectively).

Conclusion

We observed considerable improvements in BMD following treatment with the biosimilar teriparatide for one year or more. The biosimilar teriparatide can be considered as an effective treatment option in female and male patients with osteoporosis.

Impact of a diabetes disease management program on guideline-adherent care, hospitalization risk and health care costs: a propensity score matching study using real-world data

OBJECTIVE

To evaluate the impact of a DMP for patients with diabetes mellitus in a Swiss primary care setting.

METHODS

In a prospective observational study, we compared diabetes patients in a DMP (intervention group; N = 538) with diabetes patients receiving usual care (control group; N = 5050) using propensity score matching with entropy balancing. Using a difference-in-difference (DiD) approach, we compared changes in outcomes from baseline (2017) to 1-year (2017/18) and to 2-year follow-up (2017/19). Outcomes included four measures for guideline-adherent diabetes care, hospitalization risk, and health care costs.

RESULTS

We identified a positive impact of the DMP on the share of patients fulfilling all measures for guideline-adherent care [DiD 2017/18: 7.2 percentage-points, p < 0.01; 2017/19: 8.4 percentage-points, p < 0.001]. The hospitalization risk was lower in the intervention group in both years, but only statistically significant in the 1-year follow-up [DiD 2017/18: - 5.7 percentage-points, p < 0.05; 2017/19: - 3.9 percentage points, n.s.]. The increase in health care costs was smaller in the intervention than in the control group [DiD 2017/18: CHF - 852; 2017/19: CHF - 909], but this effect was not statistically significant.

CONCLUSION

The DMP under evaluation seems to exert a positive impact on the quality of diabetes care, reflected in the increase in the measures for guideline-adherent care and in a reduction of the hospitalization risk in the intervention group. It also might reduce health care costs, but only a longer follow-up will show whether the observed effect persists over time.

Walking the line between assessment, improvement and learning: a qualitative study on opportunities and risks of incorporating peer discussion of audit and feedback within quality improvement in general practice

OBJECTIVES

There is a broad call for change towards 'new era' quality systems in healthcare, in which the focus lies on learning and improving. A promising way to establish this in general practice care is to combine audit and feedback with peer group discussion. However, it is not known what different stakeholders think of this type of quality improvement. The aim of this research was to explore the opinions of different stakeholders in general practice on peer discussion of audit and feedback and on its opportunities and risks. Second, their thoughts on transparency versus accountability, regarding this system, were studied.

DESIGN

An exploratory qualitative study within a constructivist paradigm. Semistructured interviews and focus group discussions were held and coded using thematic analysis. Included stakeholders were general practitioners (GP), patients, professional organisations and insurance companies.

SETTING

General practice in the Netherlands.

PARTICIPANTS

22 participants were purposively sampled for eight interviews and two focus group discussions.

RESULTS

Three main opportunities of peer discussion of audit and feedback were identified: deeper levels of reflection on data, adding context to numbers and more ownership; and three main risks: handling of unwilling colleagues, lacking a safe group and the necessity of patient involvement. An additional theme concerned disagreement on the amount of transparency to be offered: insurance companies and patients advocated for complete transparency on data and improvement of outcomes, while GPs and professional organisations urged to restrict transparency to giving insight into the process.

CONCLUSIONS

Peer discussion of audit and feedback could be part of a change movement, towards a quality system based on learning and trust, that is initiated by the profession. Creating a safe learning environment and involving patients is key herein. Caution is needed when complete transparency is asked, since it could jeopardise practitioners' reflection and learning in safety.

A framework to improve quality of hospital-based physiotherapy: a design-based research study

BACKGROUND

A quality framework for hospital-based physiotherapy is lacking. This study aims to design a framework, building on the currently available literature, to improve the quality of hospital-based physiotherapy.

METHODS

A multidisciplinary panel of six representatives of hospital-based physiotherapy and their key stakeholders (patients, medical specialists, hospital management and professional association) was set up. We used brainwriting to sample ideas and the 'decision-matrix' to select the best ideas.

RESULTS

The first round of brainwriting with an online panel of six experienced participants yielded consensus on seven possible methods for quality improvement of hospital-based physiotherapy [1]: continuing education [2] ,feedback on patient reported experience measures and patient reported outcome measures [3] ,a quality portfolio [4] ,peer observation and feedback [5] ,360 degree feedback [6] ,a management information system, and [7] intervision with intercollegiate evaluation. Placing these methods in a decision matrix against four criteria (measurability, acceptability, impact, accessibility) resulted in a slight preference for a management information system, with almost equal preference for five other methods immediately thereafter. The least preference was given to a 360-degree feedback.

CONCLUSIONS

In the design of a framework for improving the quality of hospital-based physiotherapy, all seven suggested methods were perceived as relevant but differed in terms of advantages and disadvantages. This suggests that, within the framework, a mixture of these methods may be desirable to even out respective advantages and disadvantages.

Role distribution and collaboration between specialists and rural general practitioners in long-term chronic care: a qualitative study in Switzerland

INTRODUCTION

This study explores general practitioners' (GPs') and medical specialists' perceptions of role distribution and collaboration in the care of patients with chronic conditions, exemplified by spinal cord injury.

METHODS

Semi-structured interviews with GPs and medical specialists caring for individuals with spinal cord injury in Switzerland. The physicians we interviewed were recruited as part of an intervention study. We used a hybrid framework of inductive and deductive coding to analyse the qualitative data.

RESULTS

Six GPs and six medical specialists agreed to be interviewed. GPs and specialists perceived the role of specialists similarly, namely as an expert and support role for GPs in the case of specialised questions. Specialists' expectations of GP services and what GPs provide differed. Specialists saw the GPs' role as complementary to their own responsibilities, namely as the first contact for patients and gatekeepers to specialised services. GPs saw themselves as care managers and guides with a holistic view of patients, connecting several healthcare professionals. GPs were looking for relations and recognition by getting to know specialists better. Specialists viewed collaboration as somewhat distant and focused on processes and patient pathways. Challenges in collaboration were related to unclear roles and responsibilities in patient care.

CONCLUSION

The expectations for role distribution and responsibilities differ among physicians. Different goals of GPs and specialists for collaboration may jeopardise shared care models. The role distribution should be aligned according to patients' holistic needs to improve collaboration and provide appropriate patient care.

Administration approaches of nursing assistants in hospitals: a scoping review

OBJECTIVES

The administration of nursing assistants (NAs) is closely associated with patient outcomes, but studies evaluating intrahospital administration of NAs are limited. This study aimed to identify existing literature on intrahospital NAs' administration approaches.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Embase, CINAHL, Scopus, ProQuest, CNKI, APA PsycInfo, Wanfang Med, SinoMed, Ovid Emcare, NICE, AHRQ, CADTH, JBI EBP and Cochrane DSR were searched for articles published between January 2011 and March 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Qualitative, quantitative or mixed-method studies and evidence syntheses that evaluate administration approaches, models and appraisal tools of intrahospital NAs were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers conducted search, data selection and data extraction according to Joanna Briggs Institute guidance and methodology for scoping review. The quality of included studies was assessed using Mixed Methods Appraisal Tool or AMSTAR V.2. Data were synthesised using narrative methods and frequency effect size analysis.

RESULTS

Thirty-six studies were eligible, with acceptable quality. We identified 1 administration model, 9 administration methods, 15 educational programmes and 7 appraisal tools from the included studies. The frequency effect size analysis yielded 15 topics of the main focus at four levels, suggesting that included articles were mainly (33%) focused on the competency of NAs, and the lectures were the most (80%) used strategy in quality improvement projects. Evidence from the studies was of low-to-moderate quality, indicating huge gaps between evidence-based research and management practice.

CONCLUSIONS

Practical intrahospital administration approaches were revealed, and fifteen primarily focused topics were identified. We should explore this area more thoroughly using structured frameworks and standardised methodology. This scoping review will help managers find more effective ways to improve the quality of care. Researchers may focus more on evidence-based practice in NA administration using the 15 topics as a breakthrough.

Quality clusters in general practice: associations between cluster organization and general practitioners' self-reported benefits

BACKGROUND

Quality clusters were introduced as a quality improvement concept in Danish general practice in 2018. This new concept anchored quality improvement in local clusters managed by general practitioners (GPs).

OBJECTIVES

To describe the cluster organization and GPs' self-reported benefits of participating in them and explore the associations between cluster organization and self-reported benefits.

METHODS

A national survey in Danish general practice gathering information about cluster organization (cluster size, cluster meetings, participants, and content) and GPs' self-reported benefits (overall benefit, internal changes in the clinic, and improved external collaboration).

RESULTS

One hundred and eight (95%) clusters and 1,219 GPs (36%) were included. Cluster size varied from 10 to 68 GPs (34 GPs on average). Approximately 70% of GPs reported moderate to very high overall benefit from cluster participation. Most GPs experienced changes in their clinic organization (68%), drug prescriptions (78%), and patient care (77%). Collaboration was reported improved between the GPs (86%), municipality (50%), and hospital (36.2%). GPs in clusters with 3-6 planned meetings per year (odds ratio [OR] 1.9; confidence interval [CI] 1.3-2.9), mixed meeting types (OR 1.7; CI 1.2-2.4), group work (OR 1.7; CI 1.1-2.5), and use of guidelines in their meetings (OR 1.8; CI 1.3-2.4) had statistically significantly higher odds for reporting overall benefit of participating in clusters compared with GPs in clusters without these characteristics.

CONCLUSIONS

Frequent and active meetings with a relevant meeting content are positively related to GPs' perceived benefits and with improved collaboration between GPs in the clusters. There seems to be a potential for developing collaboration with other healthcare providers.

Implementation fidelity in a multifaceted program to foster rational antibiotics use in primary care: an observational study

BACKGROUND

The ARena study (Sustainable Reduction of Antimicrobial Resistance in German Ambulatory Care) is a three-arm, cluster randomized trial to evaluate a multifaceted implementation program in a German primary care setting. In the context of a prospective process evaluation conducted alongside ARena, this study aimed to document and explore fidelity of the implementation program.

METHODS

This observational study is based on data generated in a three-wave survey of 312 participating physicians in the ARena program and attendance documentation. Measures concerned persistence of participation in the ARena program and adherence to intervention components (thematic quality circles, e-learning, basic expenditure reimbursements, additional bonus payments and a computerized decision support system). Participants' views on five domains of the implementation were also measured. Binary logistic and multiple linear regression analyses were used to explore which views on the implementation were associated with participants' adherence to quality circles and use of additional bonus compensation.

RESULTS

The analysis of fidelity showed overall high persistence of participation in the intervention components across the three intervention arms (90,1%; 97,9%; 92,9%). 96.4% of planned quality circles were delivered to study participants and, across waves, 30.4% to 93% of practices participated; 56.1% of physicians attended the maximum of four quality circles. 84% of the practices (n = 158) with a minimum of one index patient received a performance-based additional bonus payment at least once. In total, bonus compensation was triggered for 51.8% of affected patients. Participation rate for e-learning (a prerequisite for reimbursement of project-related expenditure) covered 90.8% of practices across all intervention arms, with the highest rate in arm II (96.5%). Uptake of expenditure reimbursement was heterogeneous across study arms, with a mean rate of 86.5% (89.1% in arm I, 96.4% in arm II and 74.1% in arm III). Participants' views regarding participant responsiveness (OR = 2.298) 95% CI [1.598, 3.305] and Context (OR = 2.146) 95% CI [1.135, 4.055] affected additional bonus payment. Participants' views on participant responsiveness (Beta = 0.718) 95% CI [0.479, 0.957], Context (Beta = 0.323) 95% CI [0.055, 0.590] and Culture of shared decision-making (Beta = -0.334) 95% CI [-0.614, -0.053] affected quality circle attendance.

CONCLUSION

This study showed an overall high fidelity to the implementation program. Participants' views on the implementation were associated with degree of intervention fidelity.

TRIAL REGISTRATION

ISRCTN, ISRCTN58150046.

The WFME global standards for quality improvement of postgraduate medical education: Which standards are also applicable in Germany? Recommendations for physicians with a license for postgraduate training and training agents

Background: In Germany, the (model) regulation for postgraduate medical education 2018, the professional codes of conduct of the regional medical councils and the health professions chamber laws of the federal states are the formal basis of postgraduate medical education, but say little about its structure, processes and results. The World Federation for Medical Education (WFME) has developed global standards for improving the quality of postgraduate medical education and published them in a revised edition in 2015. A German version which takes the specifics of medical training in Germany into account has not been published to date. Objective: The Committee for Postgraduate Medical Education (PGME) of the Society for Medical Education (GMA) has set itself the goal of firstly translating the WFME standards into German and secondly making recommendations for physicians with a license for post-graduate training (PLT) and training agents (TA) in clinics and practices which have been adapted to the German context. Methods: The WFME standards were translated into German by a working group of the GMA Committee for PGME, the terminology adapted to PGME in Germany and checked by an interdisciplinary panel of experts made up of 9 members of the committee. In a second step, the WFME basic standards and quality standards for PGME relevant to PLTs and TAs in Germany were iteratively determined by this panel of experts using the Nominal Group Technique (NGT) and compiled in the form of recommendations. Results: The translation of the WFME guidelines was approved by the expert group without any changes to the content, taking into account the terminological system of PGME in Germany. In a second step, 90 standards were identified which were considered helpful for PGME in Germany, especially for PLTs and TAs (such as development of a professional identity, a more patient-centered approach or support of self-directed learning). Care was taken to only give recommendations which can be influenced by PLTs and TAs. These standards have been summarized as recommendations to PLTs and TAs and take into account all chapters of the WFME standards. Conclusion: The WFME standards selected here are recommended to PLTs and TAs in clinics and practices to achieve high-quality PGME. Empirical longitudinal studies will be required to examine both the implementation and the results of applying the modified WFME criteria in Germany.

Introducing quality clusters in general practice – a qualitative study of the experiences of cluster coordinators

Background

In 2018, the concept of clusters was introduced as a new model for data-driven quality improvement in general practice in Denmark. However, there is little research on the development and implementation of general practice clusters. The study explores how the cluster coordinators responsible for leading the clusters forward enacted and experienced their role during the early years of the clusters with attention to the challenges and enablers perceived in the process.

Methods

Qualitative, semi-structured interviews with 25 cluster coordinators from clusters that had carried out at least two meetings on a specific professional topic. The coordinators represented clusters of varying sizes and different geographic locations. Key topics in the interview guide were the development and structure of the cluster, the role of the coordinator, obtainment of data for the meetings, the role of external support, the form and content of the meetings, the participation and engagement of the members. A thematic analysis – shaped by the original aims and categories of the study while also being open to emerging themes – was performed on the transcribed interview material.

Results

Important enablers in the process of developing the clusters included the positive engagement of the GPs, the support offered by regional quality units and a national quality organisation for general practice, and the funding provided by the formal cluster framework. Challenges initially included setting up the clusters administratively and translating the open cluster concept into a local, workable model; and later obtaining relevant data for the cluster meetings and facilitating peer discussions about the data.

Conclusion

The coordinators generally experienced that the development of the clusters had progressed relatively fast with engagement from most of the participating GPs. Still, challenges with data obtainment, data analysis, and facilitation will have to be addressed ongoingly. Future research should investigate learning processes at the cluster meetings and how the clusters impact clinical practice and collaborative relations between general practice and other health care providers.

Factors associated with statin discontinuation near end of life in a Danish primary health care cohort

BACKGROUND

Long-term preventive treatment such as treatment with statins should be reassessed among patients approaching end of life. The aim of the study was to describe the rate of discontinuation of statin treatment and factors associated with discontinuation in the 6 months before death.

METHODS

This study is a retrospective cohort study using national registers and blood test results from primary health care patients. Patients in the Copenhagen municipality, Denmark who died between 1997 and 2018 and were statin users during the 10-year period before death were included. We calculated the proportion who remained statin users in the 6-month period before death. Factors associated with discontinuation were tested using logistic regression.

RESULTS

A total of 55,591 decedents were included. More patients continued treatment (64%, n = 35,693) than discontinued (36%, n = 19,898) the last 6 months of life. The 70 and 80 age groups had the lowest odds of discontinuing compared to the 90 (OR 1.59, 95% CI 0.93-2.72) and 100 (OR 3.11, 95% CI 2.79-3.47) age groups. Increasing comorbidity score (OR 0.89, 95% CI 0.87; 0.90 per 1-point increase) and use of statins for secondary prevention (OR 0.89, 95% CI 0.85; 0.93) reduced the likelihood of discontinuation as did a diagnosis of dementia, heart failure, or cancer.

CONCLUSION

A substantial portion of patients continued statin treatment near end of life. Efforts to promote rational statin use and discontinuation are required among patients with limited life expectancy, including establishing clear, practical recommendations about statin discontinuation, and initiatives to translate recommendations into clinical practice.

Understanding how and why quality circles improve standards of practice, enhance professional development and increase psychological well-being of general practitioners: a realist synthesis

OBJECTIVES

To understand how and why participation in quality circles (QCs) improves general practitioners' (GPs) psychological well-being and the quality of their clinical practice. To provide evidence-informed and practical guidance to maintain QCs at local and policy levels.

DESIGN

A theory-driven mixed method.

SETTING

Primary healthcare.

METHOD

We collected data in four stages to develop and refine the programme theory of QCs: (1) coinquiry with Swiss and European expert stakeholders to develop a preliminary programme theory; (2) realist review with systematic searches in MEDLINE, Embase, PsycINFO and CINHAL (1980-2020) to inform the preliminary programme theory; (3) programme refinement through interviews with participants, facilitators, tutors and managers of QCs and (4) consolidation of theory through interviews with QC experts across Europe and examining existing theories.

SOURCES OF DATA

The coinquiry comprised 4 interviews and 3 focus groups with 50 European experts. From the literature search, we included 108 papers to develop the literature-based programme theory. In stage 3, we used data from 40 participants gathered in 6 interviews and 2 focus groups to refine the programme theory. In stage 4, five interviewees from different healthcare systems consolidated our programme theory.

RESULT

Requirements for successful QCs are governmental trust in GPs' abilities to deliver quality improvement, training, access to educational material and performance data, protected time and financial resources. Group dynamics strongly influence success; facilitators should ensure participants exchange knowledge and generate new concepts in a safe environment. Peer interaction promotes professional development and psychological well-being. With repetition, participants gain confidence to put their new concepts into practice.

CONCLUSION

With expert facilitation, clinical review and practice opportunities, QCs can improve the quality of standard practice, enhance professional development and increase psychological well-being in the context of adequate professional and administrative support.

PROSPERO REGISTRATION NUMBER

CRD42013004826.

Contextual factors influencing physicians’ perception of antibiotic prescribing in primary care in Germany — a prospective observational study

Background

Antimicrobial resistance is a worldwide challenge for health services and systems alike. To reduce the overuse of antibiotics, multifaceted interventions are often used to achieve sustainable effects. It can be assumed that these effects are influenced by contextual factors. Embedded in the cluster randomized trial ARena (Sustainable reduction of antibiotic-induced antimicrobial resistance), the aim of this present study was to identify contextual factors associated with practitioners’ perceptions of antibiotic prescribing in German primary health care.

Methods

In a prospective observational study, data were generated in a three-wave survey study between January 2018 and July 2019. Analysis was performed using logistic regression models. The outcome of interest was the physician perceived impact of participating in the ARena project on decision-making regarding antibiotic prescribing, the independent variables of interest included individual characteristics, intervention arm allocation, primary care network (PCN) environment and characteristics of the medical practice.

Results

Forty Six point eight percent (n = 126) of participants indicated to have perceived an impact on their decision-making regarding antibiotic prescribing by participating in the ARena project. Bivariate logistic regression analyses indicated that work experience (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.006–1.103), PCN environment (OR 2.06, 95% CI 1.256–3.363), structural conditions (OR 1.66, 95% CI 1.161–2.371), environment of existing processes (OR 1.46, 95% CI 1.011–2.094), and externally defined general conditions (OR 1.57, 95% CI 1.035–2.378) were associated with physicians’ perceived impact of participating in the ARena project on decision-making regarding antibiotic prescribing. In the multivariable logistic regression analysis, only work experience OR 1.05 (95% CI 1.001–1.104) continuously showed a significant influence.

Conclusions

This study indicates that contextual factors at individual, practice, and system level influence physicians’ perceptions of antibiotic prescribing. Longer work experience appeared to be a significant influencing factor to be considered in antimicrobial stewardship programs.

Trial registration

ISRCTN, ISRCTN58150046 (registered 13.09.2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07701-3.

[Quality in statutory outpatient care: a modular system with varying approaches]

How is quality supported and what voluntary activities are there in the German statutory healthcare sector? Especially in outpatient healthcare, with a high proportion of chronic diseases treated that can significantly impair one's quality of life, quality of care is of utmost importance. We provide an overview of quality assurance measures that statutorily practicing doctors and psychotherapists (must) oblige to. Voluntary activities from third parties like doctor-specific associations and critical incidence reporting systems (CIRS) are presented alongside tools and services provided by the National and Regional Associations of Statutory Health Insurance Physicians as well as the implications of "Richtlinien" (directives) from the Federal Joint Committee and of "Qualitätssicherungsvereinbarungen" (quality assurance agreements) from the Joint Committee Quality Assurance. In summary, there is a wide spectrum of (in part voluntary) instruments and rules that is the cornerstone for the high quality present in the statutory outpatient healthcare system in Germany.

General practitioners and sales representatives: Why are we so ambivalent?

INTRODUCTION

Accepting gifts from pharmaceutical sales representatives (sales reps) or meeting them is correlated with excessive, more expensive and sometimes less rational prescribing. French general practitioners (GPs) tend to hold an unfavorable opinion of the pharmaceutical industry, yet the behavior they adopt with sales reps is generally favorable. Until now, no study has sought to explain the reasons for this discrepancy. This study explores GP experiences to better understand their ambivalent behavior.

METHOD

This qualitative descriptive study was based on semi-structured face-to-face interviews with French GPs in the south-east of France. An interpretative phenomenological approach was chosen to explore individual professional practices and to model the phenomenon through in-depth analysis of semi-structured interviews. A general inductive analysis was carried out. Data were analyzed by researchers from different disciplines (psychology, sociology and general practice).

RESULTS

Ten GPs were interviewed for an average of 50 minutes. The analysis revealed three forces that combine to motivate GPs to keep meeting sales reps despite their unfavorable opinion of these visits: practical reasons such as the need for a substitute for continuing education; social and cultural reasons such as courtesy towards representatives; and psychological mechanisms such as cognitive dissonance and a hidden curriculum.

DISCUSSION

The GP-representative relationship is complex and involves psychological mechanisms that the medical profession often fails to recognize. GPs use reps as a convenient tool for continuing education, particularly in the setting of a private practice where GPs feel pressed for time. Cognitive dissonance is a well-supported theory in social psychology that explains how a person maintains a behavior while having an unfavorable opinion of it. Since GP meetings with sales reps start during their internship, they could also be considered as part of a hidden curriculum. The strength of this work is to combine medical, social psychological and sociological perspectives with the original interpretative phenomenological approach. When the veil is lifted on individual ambivalence, the questions raised are more social and political than individual.

Effects of an interprofessional deprescribing intervention in Swiss nursing homes: the Individual Deprescribing Intervention (IDeI) randomised controlled trial

BACKGROUND

Deprescribing polypharmacy and potentially inappropriate medications (PIMs) has been shown to be beneficial to nursing home (NH) residents' health. Medication reviews are the most widely studied deprescribing intervention; in a previous trial, we showed that another intervention, a deprescribing-focused interprofessional quality circle, can reduce the use of inappropriate medications at the NH level. However, this intervention cannot account for the variety of the residents' clinical situations. Therefore, we trialled a subsequent intervention in NH that enacted the quality circle intervention in the previous year.

METHODS

In 7 NHs, the most heavily medicated residents were recruited and randomised to receive usual care or the intervention. The intervention was a pharmacist-led, deprescribing-focused medication review, followed by the creation of an individualised treatment modification plan in collaboration with nurses and physicians. Intervention's effects were assessed after four months on the number and dose of PIMs used, quality of life, and safety outcomes (mortality, hospitalisations, falls, and use of physical restraints). Data were analysed using Poisson multivariate regression models.

RESULTS

Sixty-two NH residents participated, falling short of the expected 100 participants; 4 died before initial data collection. Participants used a very high number of drugs (median 15, inter-quartile range [12-19]) and PIMs (median 5, IQR [3-7]) at baseline. The intervention did not reduce the number of PIMs prescribed to the participants; however, it significantly decreased their dose (incidence rate ratio 0.763, CI95 [0.594; 0.979]), in particular for chronic drugs (IRR 0.716, CI95 [0.546; 0.938]). No adverse effects were seen on mortality, hospitalisations, falls, and restraints use, but, in the intervention group, three participants experienced adverse events that required the reintroduction of withdrawn treatments, and a decrease in quality of life is possible.

CONCLUSIONS

As it did not reach its recruitment target, this trial should be seen as exploratory. Results indicate that, following a NH-level deprescribing intervention, a resident-level intervention can further reduce some aspects of PIMs use. Great attention must be paid to residents' well-being when further developing such deprescribing interventions, as a possible reduction in quality of life was found in the intervention group, and some participants suffered adverse events following deprescribing.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03688542, https://clinicaltrials.gov/ct2/show/NCT03688542 ), registered on 31.08.2018.

Evaluating the structural reform of outpatient psychotherapy in Germany (ES-RiP trial) - a qualitative study of provider perspectives

Background

Access to outpatient mental healthcare can be challenging for patients. In Germany, a national structural reform was implemented in 2017 to accelerate and enhance access to outpatient psychotherapy and reduce waiting times. During the first phase of the study ‘Evaluation of a structural reform of the outpatient psychotherapy guideline (ES-RiP)’ and embedded into a process evaluation, the implementation was to be evaluated through assessing general practitioners’ (GPs) and psychotherapists’ (PTs) perspectives regarding utilization of provided new measures, and perceived potential for optimization. Particular focus was on patients with a comorbidity of mental disorders and chronic physical conditions (cMPs).

Methods

This exploratory cross-sectional qualitative study used on-site and online focus group discussions and semi-structured telephone interviews with GPs and outpatient PTs. Generated data were analyzed using thematic framework analysis. Descriptive statistics were used to analyze participant characteristics collected via a socio-demographic questionnaire.

Results

Perspectives on the structural reform were heterogenous. GPs and PTs considered the component of timely initial psychotherapeutic assessment consultations beneficial. GPs disapproved of their deficits in detailed information about the structural reform and exchange with outpatient PTs. Improvement suggestions included structured short information exchange and joint quality circles. The overall number of available outpatient PTs in rural areas was perceived as insufficient. For patients with cMPs, GPs saw patient barriers for therapy access and continuity in low intrinsic motivation, physical impediments and older age. PTs also saw patient challenges regarding low intrinsic motivation and keeping scheduled appointments. They considered post-reform administrative efforts to be high and reported that the regulations (conformity) lead to planning difficulties and financial losses. Reform elements were tailored to fit in with PTs key therapy areas. Stronger networking and joint lectures were suggested as remedy for the currently still limited exchange with GPs. Unlike the GPs, PTs emphasized that accepting patients into psychotherapeutic treatment was independent of a possibly present chronic physical disease.

Conclusions

The findings contribute to understanding the integration of the delivered structural reform into daily care processes and provide an indication about reached targets and potential improvements. Further phases of the ES-RiP study can build on the findings and broaden insights.

Trial registration

Registration-ID DRKS00020344 (DRKS German Register of Clinical Trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07220-7.

Assessing Reduction of Antibiotic Prescribing for Acute, Non-Complicated Infections in Primary Care in Germany: Multi-Step Outcome Evaluation in the Cluster-Randomized Trial ARena

The three-armed cluster-randomized trial ARena (sustainable reduction of antibiotic-induced antimicrobial resistance) aimed to foster appropriate antibiotic use and reduce overprescribing in German ambulatory care to counter antibiotic resistance. Multi-faceted interventions targeted primary care physicians, teams and patients. This study examined the effectiveness of the implementation program. ARena was conducted in 14 primary care networks with 196 practices. All arms received data-based feedback on antibiotics prescribing and quality circles. Arms II and III received different add-on components each. Primary outcome examined is the prescribing rate for systemic antibiotics for cases with non-complicated acute infections (upper respiratory tract, bronchitis, sinusitis, tonsillitis, otitis media). Secondary outcomes refer to the prescribing of quinolones and guideline-recommended antibiotics. Based on pseudonymized quarterly claims data, mixed logistic regression models examined pre-post intervention antibiotic prescribing rate changes and compared to matched standard care. A significant rate reduction (arm I 11.7%; arm II 9.9%; arm III 12.7%) and significantly lower prescribing rates were observed for all arms (20.1%, 18.9% and 23.6%) compared to matched standard care (29.4%). Fluoroquinolone prescribing was reduced in all intervention arms and rates for recommended substances generally increased. No significant post-interventional difference between intervention arms was detected. Findings indicate implementation program impact compared to standard care.

Physician Assessment and Feedback During Quality Circle to Reduce Low-Value Services in Outpatients: a Pre-Post Quality Improvement Study

BACKGROUND

The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior.

OBJECTIVE

The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services.

DESIGN AND PARTICIPANTS

Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients.

INTERVENTIONS

Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018.

MAIN MEASURES

Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins.

KEY RESULTS

Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period.

CONCLUSION

Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.

Collaborative improvement in Scottish GP clusters after the Quality and Outcomes Framework: a qualitative study

Background

Scotland abolished the Quality and Outcomes Framework (QOF) in April 2016, before implementing a new Scottish GP contract in April 2018. Since 2016, groups of practices (GP clusters) have been incentivised to meet regularly to plan and organise quality improvement (QI) as part of this new direction in primary care policy.

Aim

To understand the organisation and perceived impact of GP clusters, including how they use quantitative data for improvement.

Design and setting

Thematic analysis of semi-structured interviews with key stakeholders (n = 17) and observations of GP cluster meetings (n = 6) in two clusters.

Method

This analytical strategy was combined with a purposive (variation) sampling approach to the sources of data, to try to identify commonalities across diverse stakeholder experiences of working in or on the idea of GP clusters. Variation was sought particularly in terms of stakeholders’ level of involvement in improvement initiatives, and in their disciplinary affiliations.

Results

There was uncertainty as to whether GP clusters should focus on activities generated internally or externally by the wider healthcare system (for example, from Scottish Health Boards), although the two observed clusters generally generated their own ideas and issues. Clusters operated with variable administrative/managerial and data support, and variable baseline leadership experience and QI skills. Qualitative approaches formed the focus of collaborative learning in cluster meetings, through sharing and discussion of member practices’ own understandings and experiences. Less evidence was observed of data analytics being championed in these meetings, partly because of barriers to accessing the analytics data and existing data quality.

Conclusion

Cluster development would benefit from more consistent training and support for cluster leads in small-group facilitation, leadership, and QI expertise, and data analytics access and capacity. While GP clusters are up and running, their impact is likely to be limited without further investment in developing capacity in these areas.

Progress of GP clusters 2 years after their introduction in Scotland: findings from the Scottish School of Primary Care national GP survey

Background

The concept of GP clusters is derived from 'quality circles' in general practice in Europe and Canada. GP clusters commenced across Scotland in 2016 to improve the quality of care of local populations.

Aim

To determine GPs' views on clusters, and the robustness of bespoke questions about them.

Design & setting

A cross-sectional national survey of work satisfaction of GPs in Scotland took place, which was conducted in July 2018–October 2018.

Method

An analysis of bespoke questions on GP clusters was undertaken. The questions were completed by quality leads (QLs) and all other GPs in a nationally representative sample of GPs.

Results

In total, 2456 responses were received from 4371 GPs (56.4%). QLs reported that clusters were meeting regularly, and were friendly and well organised but not always productive. Support for cluster activity (data, health intelligence, analysis, quality improvement methods, advice, leadership, and evaluation) was suboptimal. Factor analysis identified two separate constructs (cluster meetings [CMs] and cluster support [CS]), which were minimally influenced (<2%) by GP and practice characteristics. Non-QLs (75% of all GPs) were generally satisfied with the two-way communication with the cluster QLs, but the great majority (>70%) reported no positive changes in various aspects of quality improvement. Factor analysis of these items indicated two constructs (cluster knowledge and engagement [CKE] and cluster quality improvement [CQI]), which were minimally affected by GP and practice characteristics.

Conclusion

GP clusters are ‘up and running’ in Scotland but are at an early stage in terms of perceived impact and appear to be in need of more support in order to improve quality of care. The bespoke questions developed on clusters have robust construct validity, suitable for future surveys.

Psychiatry peer review groups in Australia: a mixed-methods exploration of structure and function

OBJECTIVES

The purpose of this study was to examine Australian psychiatrists' experience of participation in a small group learning format of continuing professional development, known as peer review groups (PRGs), with a particular emphasis on group structure and functions.

METHOD

An exploratory mixed-methods study comprising a survey (n=77) and semistructured interviews (n=6) with Australian psychiatrists participating in a PRG in the previous 12 months.

RESULTS

Qualitative findings indicate that PRGs address experiential learning through a focus on both breadth and specificity of work, as well as participants' experiences. Participants described using PRGs as a forum to manage difficult and complex work (through critiquing work, learning from one another, considering theory and guidelines, benchmarking, validating, reflecting and generalising learning) and to manage stress and well-being associated with crises, everyday stress and professional isolation. Particular structural aspects of PRGs considered essential to achieve these functions were self-selection of members, self-direction of meeting content and provision of a safe environment. These findings were convergent with the quantitative findings from scale survey data. Difficulties experienced during PRG participation are also described.

CONCLUSION

Qualitative and quantitative findings from psychiatry PRGs demonstrate how practice-based professional experience functions as both a source of learning and of collegial connection that contributes to well-being and reduction in professional stress. Study limitations and future research directions are discussed.

How to implement patient experience surveys and use their findings for service improvement: a qualitative expert consultation study in Australian general practice

Objective

To identify barriers (patient, provider, practice and system levels) to consider when implementing patient experience surveys in Australian general practice and enablers of their systematic use to inform service improvement in clinical practice as well as the broader health system.

Methods and analysis

An expert consultation and qualitative content analysis of cross-sectional, open-text survey data. Data were collected from key international and Australian experts in the areas of measurement and quality improvement in general practice.

Results

Responses from 20 participants from six countries were included in the study. Participants discussed the importance of ensuring value and relevance of surveys to stakeholders. Lack of resources, IT infrastructure, capacity building and sustained funding were identified as barriers to implementing surveys. Participants discussed the importance of clearly defining and communicating the purpose of surveys and agreed on the value of using patient experience to inform reflective, team-based learning at the practice level. Opinions differed on the use of patient experience data at the system level, with some questioning its utility or fairness for external performance reporting. Others recommended the aggregation and reporting of these data under certain conditions, including for the purpose of triangulation with other quality and outcome data. The study identified an evidence gap in the assessment and interpretation of patient experience data at the practice and system levels, including the analysis and contextualisation of survey findings at the system level.

Conclusion

Patient experience surveys have potential for guiding practice level quality improvement, but many barriers to their implementation remain. There is need for greater research and policy efforts to understand how this information can be used at the system level for improving Australian general practice.

Implementation and Promotion of Quality Control Circle: A Starter for Quality Improvement in Chinese Hospitals

Purpose

To analyse the quality control circle (QCC) implementation status, tool modification and promotion in hospitals in mainland China.

Methods

Data were collected from the 2013–2018 National Quality Control Circle Competition of Chinese Hospitals. A total of 1913 participating QCCs implemented by 34,023 hospital staff from 915 hospitals across 31 provinces and municipalities were included in this study to analyse the characteristics of QCC implementation status in mainland China, using descriptive analyses.

Results

The majority of participating QCCs came from central and eastern hospitals. Most of the QCCs were carried out in tertiary hospitals and focused on themes of safety and patient care. The QCC has been modified in terms of its classification, implementation process, participation mechanism, and ways of dissemination. A series of promotion strategies have been made to promote the implementation of QCCs nationwide, including establishing a professional promotion organization, developing standardized training programmes, and organizing QCC academic events.

Conclusion

After years of promotion, QCCs are widely used in hospitals and have been modified to fit the practice of healthcare institutions. The QCC promotion strategies in China can offer valuable insights for other countries that are also making efforts to continuously improve care quality in healthcare institutions.

Physician-Level Cost Control Measures and Regional Variation of Biosimilar Utilization in Germany

Biologic drugs represent a large and growing portion of health expenditures. Increasing the use of biosimilars is a promising option for controlling spending growth in pharmaceutical care. Amid the considerable uncertainty concerning physicians’ decision to prescribe biosimilars, explicit cost control measures may help increase biosimilar use. We analyze the role of regional cost control measures for biosimilars and their association with physician prescriptions in ambulatory care in Germany. We collect data on cost control measures implemented by German physician associations and national claims data on statutory health insurance covering 2009 to 2015. We perform panel regressions that include time and physician fixed effects to identify the average associations between cost control measures and biosimilar share/use while controlling for unobserved physician heterogeneity, patient structure, and socioeconomic factors. We identify 44 measures (priority prescribing, biosimilar quota) for erythropoiesis-stimulating substances, filgrastim, and somatropin. Estimates of cost control measures and their consequences for biosimilar share and use are heterogeneous by drug, measure type, and physician group. Across specialists, biosimilar quotas accounted for 5.13% to 9.75% of the total average biosimilar share of erythropoiesis-stimulating substances. Explicit quota regulations are more effective than priority prescribing. Regional variation in biosimilar use can be partly attributed to the presence of cost control measures.

Where do Peer Review Groups fit in the international Continuing Professional Development literature?

OBJECTIVES

To describe what is reported in the Continuing Professional Development (CPD) literature on small group learning formats in medicine, including the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPD Peer Review Groups (PRGs).

METHOD

A literature review of international peer-reviewed publications in relation to the use of small group learning formats for CPD in medicine.

RESULTS

Small groups are commonly used as a learning format in medical CPD, primarily in general practice, but are little researched. Such groups take differing forms and they are valued by participants for a range of purposes, having effects on professionalism, clinical performance and doctors' wellbeing.

CONCLUSION

We believe that the contribution of these groups to medical CPD should be further explored. To this end, this review forms the first part of a research project focussing on the RANZCP PRG model used by Australian and New Zealand psychiatrists.

Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians

Background

Guidelines recommend primary care physicians (PCPs) offer patients a choice between colonoscopy and faecal immunochemical test (FIT) for colorectal cancer (CRC) screening. Patients choose almost evenly between both tests but in Switzerland, most are tested with colonoscopy while screening rates are low. A quality circle (QC) of PCPs is an ideal site to train physicians in shared decision-making (SDM) that will help more patients decide if they want to be tested and choose the test they prefer.

Objective

Systematically assess CRC screening status of eligible 50–75 y.o. patients and through SDM increase the proportion of patients who have the opportunity to choose CRC screening and the test (FIT or colonoscopy).

Methods

Working through four Plan-Do-Study-Act (PDSA) cycles in their QC, PCPs adapted tools for SDM and surmounted organisational barriers by involving practice assistants. Each PCP included 20, then 40 consecutive 50–75 y.o. patients, repeatedly reported CRC status as well as the proportion of eligible patients with whom CRC screening could be discussed and patients’ decisions.

Results

9 PCPs initially included 176, then 320 patients. CRC screening status was routinely noted in the electronic medical record and CRC screening was implemented in daily routine, increasing eligible patients’ chance to be offered screening. Over a year, screening rates trended upwards, from 37% to 40% (p=0.46) and FIT use increased (2%–7%, p=0.008). Initially, 7/9 PCPs had no patient ever tested with FIT; after the intervention, only 2/8 recorded no FIT tests.

Conclusions

Through data-driven PDSA cycles and significant organisational changes, PCPs of a QC systematically collected data on CRC screening status and implemented SDM tools in their daily routine. This increased patients’ chance to discuss CRC screening. The more balanced use of FIT and colonoscopy suggests that patients’ values and preferences were better respected.

Use of quality circles for primary care providers in 24 European countries: an online survey of European Society for Quality and Safety in family practice delegates

Objective: To identify and describe the core characteristics and the spread of quality circles in primary healthcare in European countries. Design: An online survey was conducted among European Society for Quality and Safety in Family Practice (EQuiP) delegates. To allow comparison with earlier results, a similar survey as in a study from 2000 was used. Setting: Primary Health Care in European countries. Subjects: General practitioners, delegated experts of the European Society for Quality and Safety in Family Practice (EQuiP). Main outcome measures: (1) Attendance in quality circles (2) their objectives (3) methods of quality improvement quality circles use (4) facilitator's role and training (5) role of institutions (6) supporting material and data sources quality circles use. Results: 76% of the delegates responded, representing 24 of 25 countries. In 13 countries, more than 10% of general practitioners participated in quality circles, compared with eight countries in 2000. The focus of quality circles moved from continuous medical education to quality improvement. Currently, quality circles groups use case-based discussions, educational materials and local opinion leaders in addition to audit and feedback. Some national institutions provide training for facilitators and data support for quality circle groups. Conclusion: The use of quality circles has increased in European countries with a shift in focus from continuous medical education to quality improvement. Well-trained facilitators are important, as is the use of varying didactic methods and quality improvement tools. Qualitative inquiry is necessary to examine why QCs thrive or fail in different countries and systems. KEY POINTS Countries with already established quality circle movements increased their participation rate and extended their range of quality circle activities The focus of quality circles has moved from CME/CPD to quality improvement Well-trained facilitators are important, as is the use of varying didactic methods and quality improvement tools Institutions should provide supporting material and training for facilitators.