Green Book

Putting prevention into practice - Chapter 4.9

Effectiveness (and efficiency)

Key points

The PRACTICE framework:

  • Is useful when implementing preventive activities – it incorporates elements of several other theories and frameworks
  • Helps identify and overcome barriers to implementation (eg engagement, collaboration and systems)
  • Helps remind us that change is incremental and that we should plan for and recognise ‘small’ successes along the way.

The Green Book brings together two main themes: prevention and implementation.

Both of these sit within QI and are inherently associated with behaviour change.

Much time can be spent providing either ineffective care or effective care inefficiently. Effective strategies for prevention in general practice are increasingly well documented. The RACGP Standards for general practices require practices seeking accreditation to demonstrate that they use appropriate guidelines in consultations with their patients.

Box 1. Guidelines

Many guidelines have been produced to aid effective implementation of a range of prevention activities. These include the RACGP’s:

Are we strategic in our approach to implementation?

General practices are more effective when they are strategic. Specifically, they should focus on:

  • target conditions that have a significant burden of morbidity113
  • use implementation approaches that have a theoretical rationale114–121
  • areas where there is a clear and accepted role for the GP and the practice team, and the prevention target can be influenced by the actions of each
  • activities with clear aims and objectives.

Box 2. Making the process more strategic3,122–128

Questions to ask:

  • Is it important? (burden of illness)
  • Am I likely to be effective? (role, impact
  • Can I make the outcome visible? (feedback, observable/measurable)
  • What will assist getting a quick return? (reward/reinforcement)
  • Is it desirable? (congruent, win–win, all stakeholders)>
  • Is it do-able? (realistic)
  • Can we make it a routine part of the practice workflow? (sustainable)

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You may wish to improve the level of immunisation coverage against pneumococcal pneumonia in at-risk or older patients. Pneumococcal pneumonia has a significant burden in older patients, and an effective vaccine is available.

If, for example, a recent audit of this group demonstrated pneumococcal coverage of around 44%, a realistic aim would be to increase this coverage to 60% in the first instance. There is good evidence that a GP recommendation to have the pneumococcal vaccine is a significant influence on the patient’s preparedness to get the vaccine.

A GP recommendation also tends to counter any patient concerns or uncertainties about immunisation. In this instance, the focus of the intervention could include having the target population identified on their medical records so that when they attend the practice, the GP or PN is prompted to offer the pneumococcal vaccine.

– Assoc Prof John Litt, Green Book Editorial Committee


Do we use effective strategies?

Some examples of effective strategies that support improved prevention performance in general practice include:

  • identifying and instituting a prevention coordination role within the practice
  • securing the services of a PN
  • developing a strong, multidisciplinary teamwork approach
  • ensuring good information management systems for efficiency
  • making the best possible use of existing partnerships, PHNs and other community supports.

There are many technology-based implementation strategies (eg using an app to promote changes to diet), but for some there is inconclusive evidence to support their effectiveness. If you choose to use interventions such as apps as part of your preventive programs, the outcomes should be carefully monitored.

The RACGP’s Handbook of non-drug interventions (HANDI) provides examples of some effective apps.

The RACGP also has released the resource mHealth in general practice: A toolkit for effective and secure use ofmobile technology.

Effective implementation strategies and processes are described in Table 4. Strategies that tend to be less preferred by GPs can often be more effective (eg practice register and reminder systems, team meetings, appointment of a prevention coordinator).

Table 4. Effectiveness of implementation strategies

Table 4

Effectiveness of implementation strategies

Adding implementation strategies does not necessarily increase the level of performance. The process needs to be strategic. It should:

  • address practice systems and infrastructure
  • provide adequate leadership (eg local champion, planning and coordination)
  • encompass a wide array of strengths, skills, resources and competencies.

Do we use time effectively?

It does not always follow that spending an increased amount of time with a patient on a preventive issue leads to a proportionally better outcome. For example, spending 20 minutes counselling a patient who smokes does not necessarily provide four times the benefit of spending just five minutes counselling the same patient.

Sometimes less is more, and you may be more effective by providing some components of the prevention activities to all patients than providing considerable input to fewer patients. The ‘reality pyramid’ provides an incremental and systematic strategy to improve the delivery of lifestyle advice in the GP setting, using smoking cessation as an example (Figure 8).

Writing down the various intervention components and the chronological sequence of steps will also help the implementation to be more systematic.

Figure 8. Reality pyramid for smoking cessation

Figure 8

Reality pyramid for smoking cessation

Reproduced with permission from Litt JCB, Shelby-James T, Edwards D. GASP (GPs Assisting Smokers Program): Final report to the SA AntiTobacco Ministerial Advisory Taskforce. Adelaide: GASP, 2002.


The pyramid highlights the ‘less is more’ (one minute for prevention) approach. The base level of the pyramid outlines the practice infrastructure that supports the GP (and others) to provide preventive care. It emphasises the value of teamwork and demonstrates that using other practice resources and establishing appropriate reminder and referral systems can facilitate brief interventions. It supports the notion that it is unrealistic to expect the GP to be the sole provider of preventive care within the practice. It provides a prompt for the best use of time during a consultation, starting with a very brief intervention for most patients and then using more intense strategies with fewer patients. The interventions should cover the activities likely to have the biggest impact for the patient in most circumstances. It recognises that spending more time is often necessary, but reflects the reality that most GPs have about a minute of ‘disposable’ time to raise and/or discuss an issue they think is pertinent and important to the patient. The one minute can be spent in a number of ways:

  • focusing on specific evidence-based guidelines
  • justifying why an additional consultation is worthwhile (you might suggest to the patient that the unassisted quit rate is around 3–7%, whereas with GP assistance, together with external support, this success rate can be boosted fourfold to sixfold;218–220 given the difficulty with quitting, anything that helps maximise success seems a sensible choice, provided it is acceptable to the patient)
  • justifying why seeing someone else (eg PN) may be helpful
  • outlining the value and effectiveness of the Quitline.
– Assoc Prof John Litt, Green Book Editorial Committee
 

Do we apply effort effectively?

Considerable effort may be required before you begin to see change. Things may then proceed relatively smoothly with less effort. Reaching the final stage of desired improvement may also require extensive effort. For example, moving from 90% to 100% vaccination coverage may take more effort than getting to the 90% in the first place.

An effective preventive intervention should also be delivered efficiently. It needs to be incorporated into the practice routine without creating significant extra work in order to be sustainable.

It is not possible for general practices to provide all recommended prevention services. You need to decide where to focus attention in order to deliver the best possible outcomes with the available resources for the groups of patients targeted. Some useful questions to consider are:

  • What is the cost and staff time to do this?
  • Does it make good business sense?
  • Are there any resources that you are underusing, or are you duplicating services?

For example, GPs may continue to be offering the influenza vaccine to patients they are seeing rather than getting the PN to run a flu vaccination clinic. Using the latter strategy would give the GP more time to talk to the patient about other important medical issues.

Does it fit with our practice and our culture?

To make prevention processes sustainable, ensure that the process is:221,222

  • adapted to the local context
  • consistent with the practice and professional goals
  • integrated into workflows so that, where possible, it doesn’t take more time.

It is important to also monitor and review practice procedure and policy manuals, clarify roles and tasks, appoint a coordinator and encourage all staff to contribute.223 You will need to ensure that the QI process incorporates a review of the outcomes.

What is the most important contribution we can make?

GPs and practice teams should complement prevention activities by using effective or more efficient population- based or community-based prevention strategies. Examples include:

  • population screening programs (eg breast screening, cervical screening, bowel screening)
  • population registers (eg immunisation register, cancer registers)
  • screening for familial disease (eg family history questionnaire for cancer, heart disease and diabetes), which is often under-recorded
  • childhood health programs (eg Healthy Kids weight management resources for health professionals)
  • media strategies to address issues such as smoking cessation and hazardous drinking.

Most established national programs have reached coverage of 50–60% (eg BreastScreen Australia, 54% participation;224 cervical screening, 56% participation225). GPs are key influencers in screening participation and play a significant role in improving coverage.226,227


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Putting it all together with a complex patient: Case study

The patient, female, aged 91 years, is a war widow living alone in a suburban area, with one son (aged in his 70s) living a 15-minute drive away. She has multiple comorbidities:

  • vasculopathy (coronary artery bypass graft and small cerebrovascular accident)
  • biventricular failure, well controlled on diuretic
  • unstable angina
  • ‘burnt out’ rheumatoid arthritis
  • anxiety disorder/multiple phobias
  • low BMI, frail, with falls risk and accidental injury risk both high
  • multiple drug allergies/intolerances.

She has had frequent hospital admissions related to left ventricle function, unstable angina and injuries. The patient goals are to:

  • stay at home (when she is no longer able to go out for lunch) and die there
  • not be a burden to her son
  • avoid admission to two out of three local hospitals at all costs (she has a phobic reaction to two).

The GP aims and goals are to:

  • allow the patient to stay in her own home as long as possible
  • give her a sense of control over her healthcare transactions
  • avoid identified risks.
  • The main risks are:
  • falls and injuries
  • medication misadventure post-hospital admissions
  • unavoidable nursing home admission.

Who helped the practice and you as GP?

We looked at what the Coordinated Veterans’ Care (CVC) program offered. Strategies employed within the CVC program to manage risks and support patient goals:

  • The GP is supported to operate within a community team structure, independent of extended primary care (EPC) structures, and to do ‘non–face-to-face’ work/extended liaison.
  • The PN role is able to expand and consolidate, evolving into a pivotal role, formalised in broad enablers (improved coordination and collaboration; better targeting of care and identification of barriers; improved ability of the PN, the patient and the patient’s family to identify and manage issues as they arise; improved efficiency). The PN is involved in day-to-day management under CVC funding.

What did you do to make it happen?

  • Drilling down – we wrote the above features into a CVC plan and reviewed this regularly to ensure implementation was happening as it should and to explore opportunities to expand.
  • We involved the PN from the beginning.
  • The GP was supported to work within a team structure, especially before, during and after admissions to hospital. This overcame the barrier imposed by the descriptor around use of EPC case conference items.

What specific strategies did you use?

  • Congestive cardiac failure (CCF) – early detection via phone of exacerbation of health problems, with added opportunity to conduct wider phone assessment as indicated.
  • Employed sick day management plan as required for the patient.
  • A shared plan around emergency admissions – we organised a direct link for patient or son by mobile phone with the GP if an ambulance crew was attending. The GP would speak to the crew and emergency department (ED) at the only hospital acceptable to the patient and arrange transfer (this was often critical, as private EDs are frequently ‘on bypass’ and crews are otherwise instructed to transport all patients to a public ED). This strategy came into play about once yearly.
  • Advocacy and active contribution to management during hospital admission (eg GP successfully advocated to arrange blood transfusion prior to discharge after skin graft for shin wound, resulting in symptomatic improvement in CCF and [likely] accelerated healing)
  • Better clarification of roles and responsibilities.

CVC enables an individualised and high-quality (bespoke) plan by acknowledging several factors that enable this type of more detailed and dynamically responsive care.

What outcomes/improvements do you think you achieved?

  • Vastly enhanced patient confidence that her needs were being met
  • High-level support for son
  • Readmission avoidance
  • Tight medication control
  • Good time management (minimisation of wastage from poor communication)
  • Team satisfaction with results and a sense of cohesion

What made the most difference?

Communication made the biggest difference.

The involvement of the PN in this new level of communication was paramount, with a move away from a narrow role of relaying messages and basic triage.

Central to this was the formalisation of this broader role of the PN through the renaming of this role in the CVC descriptor. Our nurses were pleased to embrace this recognition.

Instead of having the PN conduct a holistic health assessment once a year, this occurred on a continuous basis.
The program gave the PN a sense of ownership and provided the PN with an extra quarterly payment as a reward for extra effort. Other advantages were in:

  • talking through issues, conducting phone and onsite assessment, trouble shooting and safety netting
  • liaison with family, being able to include them in real-time decision-making.

What would you say to GPs who may consider doing similar things? What would you do differently?

Meet face to face more often with key community care team members for optimal shared understanding when a situation becomes critical (eg trying to avoid an admission).

For frail, elderly people with multimorbidity at home, the ground can shift in a 24-hour period. Micromanagement is necessary to prevent deterioration in health status with ensuing hospital admissions or nursing home attendance.

Relationships are crucial to the success of these strategies – most older people cling to the advice of those, and only those, they trust. This is why they sometimes wait for their own physician to return from leave.

Enacting the detail of a care plan is important, with, for example, weekly phone-ins and maintaining a current weight or fluid chart.

A ‘hospital in the home’ set-up can be achieved in a limited fashion if parameters are clearly defined. Twice-daily review for 2–3 days can be very effective. Geographic proximity is important.

You can keep someone at home with diarrhoea and heart failure for one night, but only if you can check on them the next day.

Liaison with a pharmacist is more vital than ever, with multitudes of brands of drugs and dwindling commitment to providing continuity of personnel or product. Frequent checking of packets for errors will help avoid medication misadventure.

Having a person stay at home sick rather than go to hospital requires confidence in covering the dusk-to-dawn phase (eg ensuring the patient/carer has a number they can call if things go wrong).

In the case described, our patient required someone to direct the ambulance to the correct ED.

In terms on return on effort, do you think the whole process was worthwhile?

Very much so! Basically, this is how I was already operating but didn’t feel like I could ask much of our PN without dedicated funding.

The feedback from patient and family was superb, and we even regularly heard second-hand from others (eg the ambulance service) about how well the system worked and how different it was from normal care.

– Dr Christine Boyce, Hobart GP

 

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