Correspondence: Michel Wensing, Radboud University Nijmegen Medical Centre, Scientifi c Institute for Quality of Healthcare, PO Box 9100, 6500 HB, Nijmegen, the Netherlands. Fax: 0031 34 3540166. E-mail: m.wensing@iq.umcn.nl

(Received 2 September 2012 ; accepted 17 October 2012 )

Background Paper

Improving the quality of care for patients with chronic diseases: What research and education in family medicine can contribute

Michel Wensing 1 & Janko Kersnik 2

1 Radboud University Nijmegen Medical Centre, Scientifi c Institute for Quality of Healthcare, Nijmegen, the Netherlands, and 2 University Ljubljana and Maribor Medical School, Department of Family Medicine, Ljubljana, Slovenia

ABSTRACT Background: The theme of the EGPRN conference in Ljubljana 2012 was ‘ Quality improvement in the care of chronic disease in family practice: the contribution of education and research. ’ Objective: In this contribution, we summarize our key note lectures and provide refl ections on the theme. Results: Many countries have established programmes for training of primary care professionals and quality improvement in family medicine. Research and development has focused on new educational methods, practice accreditation, patient safety in primary care, models of structured chronic care, and tailored improvement.

Conclusion: An international academic network of physicians, teachers and researchers in primary care should be nurtured to address the challenges of chronic illness care.

Key words: Primary care , continuing education , quality improvement

INTRODUCTION

Ageing, lifestyle changes, and medical advances have made chronic non-communicable diseases leading causes of morbidity and mortality all over the globe. Many patients with these diseases are treated in primary care (1). This poses a range of challenges for family phy-sicians and other primary care professionals. They are expected to use the best available knowledge in their decisions, to possess a wide range of clinical skills, and to be eff ective co-ordinators of care for their patients. They have to respect their patients ’ preferences at all times and involve them actively in the care received. In many countries, family physicians are also responsible for a reliable and effi cient organization of their practice

organization, including the supervision of other health-care workers, such as nurses and assistants. Family phy-sicians have to meet challenges in a context of rapid spread of modern information technology and access to the World Wide Web, societal worries about rising costs of healthcare, and concerns about the shortage of the work force in healthcare. How can research and teaching in family medicine help to address these challenges?

The theme of the EGPRN conference in Ljubljana 2012 was ‘ Quality improvement in the care of chronic disease in family practice: the contribution of education and research. ’ While this is a bit of an ‘ evergreen ’ — the topic has attracted interest for several decades — the orga-nizers were interested to discuss recent developments

European Journal of General Practice, 2012; 18: 238–241

ISSN 1381-4788 print/ISSN 1751-1402 online © 2012 Informa HealthcareDOI: 10.3109/13814788.2012.742059

KEY MESSAGE(S):

· Well trained family physicians participating in quality improvement projects are crucial for primary care. · Recent research focused on educational methods, practice accreditation, patient safety, models of chronic care, and tailored

improvement. · Addressing the challenges of chronic illness care implies nurturing an international academic network of physicians,

teachers and researchers in primary care.

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EGPRN conference 2012 paper 239

in research and education in family medicine. In this con-tribution, we will summarize our key note lectures and give some further refl ections on the theme.

DEVELOPMENTS IN EDUCATION

It is widely understood that a strong primary care is an essential constituent of each health care system, which has a positive impact on health outcomes, equity, and healthcare costs (2). Well trained primary care physicians are crucial for strong primary care. Here, we focus mainly on family medicine as the discipline that is responsible for primary medical care in many countries. Family med-icine provides key information on the epidemiology of diseases, and is an important place of training of health professionals because most patients contact primary care before, during, and after specialized treatments (3). Family practice has, therefore, a unique task profi le, which is not an addition of the task profi les and expertise of other disciplines taught in medical schools (4).

Guidelines for training family physicians have become available. A European Union Directive asks from member states at least three years of specialist training in family practice, half of which should take place in a primary care setting (5). The European academy of teachers (EURACT) has played an important role in exchanging expertise and guiding educational activities in family practice in Europe (6 – 8). It has defi ned an educational agenda, which includes principles for teaching the disci-pline. Comprehensive care is one of the core principles and continuity of care is a prerequisite of high quality family practice. Integrated, comprehensive patient man-agement should encompass health promotion, disease prevention, early detection and treatment as well con-tinuous management and palliation. Principles of com-prehensive management are: knowing your patients (lists), active seeking of patients at risk for disease devel-opment or ill, developing disease registers, teamwork, community orientation, patient groups education and targeted activities in accordance with local and societal needs. One of the key points of our future endeavours in the training of family physicians is the translation of biomedical science into meaningful practice recommen-dations, such as adaptation of advanced diagnostic tests and treatments for use in primary care.

Many countries introduced programmes of care for long-term conditions to improve patient care and to con-trol healthcare costs. Various chronic care models have emerged and passed, but continuity of care of chronic patients remains a key target of family medicine. We should avoid feeding computers with data if this is only useful for the management of a programme for struc-tured chronic care (9). Patient records should serve patient care, respect patients ’ preferences and ideally also enhance their self-management. Therefore, medical students and vocational trainees in family medicine

should also be taught in communication skills, team work, practice organization, and knowledge manage-ment. In addition, they should develop specifi c attitudes regarding excellence, humanism, accountability and altruism (10). Innovations, such as the use of art in teach-ing professional attitudes, for example movies are con-sistent with these principles (11). Instruct teachers to role model and teach future doctors in the art of family medicine as core primary health care discipline is of utmost importance to maintain professionalism in spite of politic drifts (4).

DEVELOPMENTS IN RESEARCH

Many organizations of family physicians and health authorities across the world invested in educational pro-grammes to improve primary care. Examples are clinical audit, quality circles, computerized decision support, and web-based learning. Programmes for accreditation of family physicians and primary care practice organiza-tions build on these educational approaches (12). Accreditation programs have a range of purposes, includ-ing but not limited to quality improvement. The assess-ment for accreditation may focus on a variety of domains. For instance, the programme for accreditation of general practices in the Netherlands is strongly focused on orga-nization and delivery of care for patients with chronic diseases. Ongoing research aims to assess whether accreditation eff ectively improves healthcare. A study in German family medicine found that a particular practice accreditation programme, which used the internation-ally validated EPA instrument (European Practice Assess-ment), led to improvements in a range of organizational domains (13). A study on the eff ectiveness of practice accreditation in the Netherlands (a cluster randomized trial focused on patients with chronic cardiovascular con-ditions) will report results in the coming years.

Patient safety obviously has always been an impor-tant component of quality of care, but in recent years it has gained extensive interest. In essence, patient safety means absence of preventable harm to patients. Initially, the emphasis was strongly on patient safety in hospitals, but more recently safety of primary care has also received attention. Patient safety incidents in family practice do occur, but their incidence is much lower than in hospital settings (14). While patient safety is potentially very broad, incidents with a high risk of harm tend to relate to the diagnosis and treatment of major chronic dis-eases. The challenge in primary care is to enhance patient safety, but avoid defensive medicine and heavy administrative programmes. When asked, family physi-cians prioritized educational tools related to patient safety and initiatives to improve patient safety culture (15). In some countries, major investments were made in research and development to improve patient safety in family medicine. In other countries such investments

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240 M. Wensing & J. Kersnik

have not yet been made, or have stopped because of change of political priorities.

A perhaps simple, but hardly implemented, insight from implementation science is that interventions to improve healthcare should be tailored to relevant barri-ers and enablers for change (16). This is the same as in patient care, where patients receive treatments that are tailored to diagnosis or working defi nitions of their health problems. Likewise, to improve performance, not every family physician needs the same type of inter-vention — whether educational, organizational, fi nancial, or otherwise. More research is needed on methods for tailoring, because little is known about the values and limitations of various methods. For instance, tailor-ing varies from a two-hour brainstorm in a group of clinicians to a nine-month structured intervention mapping process. In an ongoing European study, we explore diff erent methods for tailoring implementation interventions, focusing on improving chronic illness care (17).

In addition to educational activities to support family physicians, it is crucial to optimize the organization of primary care to meet the challenges of caring for patients with chronic diseases. The Chronic Care Model (CCM), which is supported by the American College of Family Physicians, is a concept suggesting how such optimally organized healthcare looks like. It proposes several qual-ity improvement interventions (including organizational structures) related to the design of the clinical process, information technology, decision support, and self-man-agement support. The model is popular among policy makers in many countries, but its relevance to European primary care is not well studied. The evidence on cost-eff ectiveness of chronic care models is still limited as yet (18). Interestingly, a study of an approach that resem-bled elements of the Chronic Care Model found that only diabetes patients with co-morbidities showed better quality of life compared to usual care (19).

DISCUSSION

In this paper, we summarized our presentations at the EGPRN conference in Ljubljana, which focused on developments in education and research in family medicine related to the care for patients with chronic diseases. In this fi nal section, we will provide some further refl ections on this theme.

The assessment of clinical and organizational pro-cesses and outcomes remains a key component in both training of health professionals and quality improve-ment. The introduction of evidence based medicine should not be interpreted as a requirement to follow practice guidelines blindly in all situations. Teaching complexity, communication skills, patient involvement and adherence, medical professionalism and humanism should be at the core of family practice teaching (20).

A related misconception is that computerized medical records and decision support systems will automatically improve healthcare. In fact, their impact is moderate (21). We believe that the best available knowledge should always play a role in clinical decision making, but that few (if any) recommendations for clinical practice should be followed at all times. An important area of future research is, therefore, the development of mea-sures that better capture the use of knowledge by health professionals and patients in daily practice.

Family medicine was among the fi rst medical profes-sions to develop and evaluate programmes for quality improvement. Notably, performance measures now often have a broad set of purposes. Besides quality improvement, these include quality control, accountabil-ity in relation to contracts, pay for performance, public reporting, and marketing. There are risks associated with these new purposes. For instance, patient privacy and autonomy may be threatened by widespread use of and access to computerized data. Methods that focus heavily on measuring and streamlining performance may reduce patients to organs, diseases and target values. Paying for performance may be benefi cial for improvement in tar-get areas, but may be causing inequalities in the disease or other characteristics not included in the payment package. We believe that quality improvement should remain the core of performance measurement and that active involvement of healthcare professionals is required actually to improve organization and delivery of health services. Both, professional training and research should prioritize the broad implementation of eff ective quality improvement programmes, and future studies should help to optimize such programmes by providing insight into determinants of their eff ectiveness.

We cannot ignore the realities of a continuously growing body of knowledge, rising costs of healthcare, and disappointingly poor quality in some area of health-care. Policy makers, funders of healthcare, and managers of healthcare have only limited means to address these challenges. Well-developed, complementary and col-laborating international academic networks of physi-cians, teachers and researchers in primary care are needed to address these challenges. No profession can survive (as a profession) without such knowledge infra-structure. Concepts like the ‘ chronic care model ’ or ‘ pay for performance ’ have been coined, perhaps with good intentions, but they imply an ideology focused on intro-ducing management and economic concepts in health-care (22). It is crucial to keep the interests of patients and populations at the centre of our work.

FUNDING

Research reported in this contribution is funded by several research funders, including the European Com-mission and the Netherlands Organization for Health Research (ZonMW).

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EGPRN conference 2012 paper 241

Wong ST , Peterson S , Black C . Patient activation in primary health-9. care . A comparison between healthier individuals and those with a chronic illness. Med Care 2011 ; 49 : 469 – 79 . Mueller PS . Incorporating professionalism into medical educa-10. tion: The Mayo Clinic experience . Keio J Med. 2009 ; 58 : 133 – 43 . Klemenc-Ketis Z , Kersnik J . Using movies to teach professionalism 11. to medical students . BMC Medical Educ. 2011 ; 11 : 60 . Lester H , Eriksson T , Martinson K , Tomasik T , Sparrow N . Practice 12. accreditation: The European perspective . Br J Gen Pract. 2012 ; 62 : e390 – 2 . Szecsenyi J , Campbell S , Broge B , Laux G , Willms S , Wensing M , 13. et al . Eff ectiveness of a quality-improvement program in improving quality of primary care practices . Canadian Medical Association Journal 2011 ; 183 : E1326 – E1333 . Gaal S , Verstappen W , Wolters R , Lankveld H , Van Weel C , 14. Wensing M . Prevalence and consequences of patient safety incidents in general practice in the Netherlands: A retrospective medical record review study . Implem Sci. 2011 ; 6 : 37 . Gaal S , Verstappen W , Wensing M . What do primary care physi-15. cians and researchers consider the most important patient safety improvement strategies? BMC Health Serv Res. 2011 ; 11 : 102 . Wensing M , Bosch M , Grol R . Developing and selecting interven-16. tions for translating knowledge to action . Canadian Medical Asso-ciation Journal 2010 ; 182 : E85 – 8 . Wensing M , Oxman A , Baker R , Godycki-Cwirko M , Flottorp S , 17. Szecsenyi J , et al . Tailored Implementation for chronic diseases (TICD): A project protocol . Implem Sci. 2011 : 6 : 103 . de Bruin SR , Baan CA , Struijs JN . Pay-for-performance in disease 18. management: A systematic review of the literature . BMC Health Serv Res. 2011 ; 11 : 272 . Ose D , Wensing M , Szecsenyi J , Joos S , Hermann K , Miksch A . 19. Impact of primary care based disease management on health-related quality of life in patients with type 2 diabetes and co-morbidity . Diab Care 2009 ; 32 : 1594 – 6 . Klemenc-Ketis Z , Kersnik J . Role of European academy of teachers 20. in family practice in family medicine education in Europe — University of Maribor experiences . Acta Med Acad. 2012 ; 41 : 80 – 87 . Black AD , Car J , Pagliari C , Anandan C , Cresswell K , Bokun T , et al . 21. The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview . PLoS Med 2011 ; 8 : e1000387 . Singh D . How can chronic disease management programmes 22. operate across care settings and providers? Bangkok, Thailand, WHO; 2008 . Available at http://www.euro.who.int/__data/assets/pdf_fi le/0009/75474/E93416.pdf (accessed 10 May 2012).

Declaration of interest: The authors report no confl icts of interest. The authors alone are responsible for the content and writing of the paper.

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