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Using Run Charts for Cardiovascular Disease Risk Assessments in General Practice

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Using Run Charts for Cardiovascular Disease Risk Assessments in General Practice ORIGINAL SCIENTIFIC PAPER IMPROVING PERFORMANCE Using run charts for cardiovascular disease risk assessments in general practice Susan Wells MBChB, DipObs, MPH, PhD, FRNZCGP, FNZCPHM;1 Natasha Rafter MBChB, DRACOG, MPH, FNZCPHM, FAFPHM, MFPHMI;2 Kyle Eggleton BHB, MBChB, DipObstMedGyn, DipPaed, DIH, PGDipPH, MMedSci, FRNZCGP;3 Catherine Turner RN, RM, PG Dip HEIN, PG Dip PHC;4 Ying Huang BNur, PGDiPSci, MSc;1 Chris Bullen MBChB, DObst, DCH, MPH, PhD, FAFPHM, FNZCPHM5 1 Section of Epidemiology and Biostatistics, School of Population Health, ABSTRACT University of Auckland, New Zealand INTRODUCTION: Run charts are quality improvement tools. 2 Senior Lecturer, Royal College of Surgeons in AIM: To investigate the feasibility and acceptability of run charts displaying weekly cardiovas- Ireland cular disease (CVD) risk assessments in general practice and assess their impact on CVD risk 3 Department of General Practice and Primary Health assessments. Care, School of Population Health, University of METHODS: A controlled non-randomised observational study in nine practices using run charts Auckland, New Zealand and nine control practices. We measured the weekly proportion of eligible patients with com- 4 Population Health pleted CVD risk assessments for 19 weeks before and after run charts were introduced into Strategist/Analyst, intervention practices. A random coefficients model determined changes in CVD risk assess- Northland Primary Health Organisations ment rates (slope) from pre- to post- intervention by aggregating and comparing intervention 5 Director, The National and control practices’ mean slopes. We interviewed staff in intervention practices about their Institute for Health use of run charts. Innovation (NIHI), School of Population Health, RESULTS: Seven intervention practices used their run chart; six consistently plotting weekly data University of Auckland, New Zealand for >12 weeks and positioning charts in a highly visible place. Staff reported that charts were easy to use, a visual reminder for ongoing team efforts, and useful for measuring progress. There were no significant differences between study groups: the mean difference in pre- to post-run chart slope in the intervention group was 0.03% more CVD risk assessments per week; for the control group the mean difference was 0.07%. The between group difference was 0.04% per week (95% CI: –0.26 to 0.35, P = 0.77). DiSCUSSION: Run charts are feasible in everyday general practice and support team process- es. There were no differences in CVD risk assessment between the two groups, likely due to national targets driving performance at the time of the study. J PRIM HEALTH CARE 2016;8(2):172–178. Cardiovascular diseases; risk assessment; primary care; run charts; quality 10.1071/HC15030 KEYWORDS: improvement CORRESPONDENCE TO: Susan Wells Section of Epidemiology Introduction who are of Māori, Pacific or South Asian ethnic and Biostatistics, School groups, or have known CVD risk factors.1 of Population Health, In New Zealand, cardiovascular disease (‘CVD’) Management recommendations are based on University of Auckland, guidelines recommend screening for CVD and P.O. Box 92019 Auckland five-year CVD risk stratification, with greater the Mail Centre, Auckland diabetes in all men aged >45 years, all women intensity of lifestyle and medication management [email protected] aged >55 years and 10 years earlier for people recommended for people with higher estimated 172 Journal Compilation © Royal New Zealand College of General Practitioners 2016 This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License ORIGINAL SCIENTIFIC PAPER IMPROVING PERFORMANCE CVD risk.1 If fully implemented, this targeted approach could reduce future CVD events by an WHAT GAP THIS FILLS estimated 50% or more.2 What is already known To encourage CVD risk assessment, the Ministry • Run charts plotting changes in care processes over time have of Health introduced a primary care performance been used in hospital and ambulatory settings for some time target in 2012: to achieve 60% of the eligible to monitor quality improvement activities but their use in New population having a CVD risk assessment (includ- Zealand general practice is not widespread. ing screening for diabetes) by July 2012, 75% by July 2013, and 90% by July 2014.3 The target What this study adds was accompanied by a modest financial incen- tive paid to primary health organisations (PHOs) • Run charts in general practice for displaying weekly CVD risk and public benchmarking of PHO performance. assessments were useful for helping teams focus and galvanise In 2012, we estimated that approximately half of their efforts. the eligible population from the Northland and • No difference was found in the CVD risk assessments between Auckland regions had been risk assessed (Wells, intervention and control practices but this lack of effect may have S. unpublished). To support practices to achieve been due to multiple practice and PHO interventions to attain their targets we considered that run charts may national CVD risk assessment targets at the time of the study. be useful. A run chart is a simple visual display of data over time that provides a dynamic view of the performance of a care process within a health service.4–6 Run charts are also used to determine if care practice use a web-based computerised interventions have resulted in improvement and decision support tool (PREDICT)8 to conduct if improvements are sustained.7 Run charts can be CVD risk assessments for their eligible popula- applied when other methods to determine statisti- tion. CVD risk profiles of individual patients cal significance are not useful.5 Run charts have are sent via secure messaging to the PREDICT been used in hospital and ambulatory settings server and within seconds a CVD assessment for some time to monitor quality improvement score is calculated and returned to the practice activities6,7, but their use in New Zealand general to be saved in each patient’s electronic medical practice is not widespread. record. Encrypted risk profiles for the two PHOs are also stored on a secure server housed by The aims of this study were to investigate the Enigma Solutions Ltd on behalf of the two PHOs. feasibility and acceptability of run charts that Practices can check their weekly counts of CVD display weekly CVD risk assessments in a group risk assessments (and estimated proportion of the of Northland general practices and to determine eligible population assessed) if they choose. The whether this tool might help to increase the rate investigators received permission from the study of eligible, enrolled patients having a CVD risk PHOs to access anonymised aggregated count assessment. and proportion data stratified by practice. Methods At the time of the study 20 practices in the PHOs already participated in the EPOCH trial, The study was conducted in Northland general a randomised controlled trial of point of care practices from November 2013 until 31 July testing (POCT) for HbA1c and cholesterol. As 2014. Primary health care in Northland is de- the primary outcome of the trial was completed livered by 39 general practices belonging to two CVD risk assessments in eligible patients, the PHOs – Manaia and Te Tai Tokerau. The PHOs trial 20 practices were excluded as run charts share common information services, popula- would represent a co-intervention making it dif- tion health monitoring and clinical directors. In ficult to tease out the impact of each intervention addition, the PHOs employ facilitators who sup- separately. After excluding one practice not using port individual practices in achieving population PREDICT, investigators asked the remaining 18 health targets. All except one Northland primary practices if they would be interested in trying VOLUME 8 • NUMBER 2 • JUNE 2016 JOURNAL OF PRIMARY HEALTH CARE 173 ORIGINAL SCIENTIFIC PAPER IMPROVING PERFORMANCE out run charts. Nine practices accepted this The control practices did not receive a run chart invitation; the remaining nine practices provided or the instruction visit. At the end of the study, the control group. investigators (CT and SW) visited intervention practices and interviewed practice staff. The main study outcome was the weekly propor- tion of eligible patients with completed CVD Quantitative analysis risk assessments. Weekly counts of completed CVD risk assessments were compared for the We used a random coefficients model to determine nine intervention and nine control practices. To whether there was a change in rate of CVD risk determine whether changes in risk assessment assessment (slope) from pre- to post- interven- may be attributable to the run chart, weekly tion by aggregating the mean slopes from the nine data points for every practice were collected for practices in the intervention group and comparing 19 weeks before introducing the run chart (i.e. that to the mean slopes achieved by the nine con- baseline practice performance). These data (from trol group practices. The unit of analysis was the 14 Nov 2013 to 20 Mar 2014) were plotted on practice and the percentage of eligible patients with a paper run chart for each practice (Figure 1). a completed CVD risk assessment was the primary For the intervention practices, PHO facilitators outcome. The model has both fixed effects and visited and provided brief instructions on how to random effects. The fixed effects were the changes fill them in and to continue plotting
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