Quality in Primary Care Open Access

Keywords

care pathway, critical pathways (mesh), hospitals (mesh), primary health care (mesh), quality improvement

Introduction

Care pathways are widely used in hospitals to improve quality of care.[1,2] The effect of a care pathway is most pronounced in hospital when these are used for high volume or complex treatments.[3] There is growing interest in extending care pathways into primary care.[4] There is little evidence on the relationship between care pathways across the primary–hospital care continuum and quality improvement.[5,6]

Patients treated with a radical prostatectomy need complex primary and hospital care, based on well organised co-ordination and communication.[7–10] It is very important to inform and involve patients in the care process.[11] As these patients tend to have symptoms of urinary incontinence,[12] pelvic floor muscle exercise (PFME) treatment should be considered as one of the key interventions for patients before and after surgery.[13]

In 2005, primary care and a hospital team in the Bruges region (Belgium) extended the care pathway that had already been developed in hospital for prostatectomy. An evaluation of the newly extended care pathway encountered the following problems: (1) caregivers considered the information pack consisting of agreements made about the care process, checklists, guidelines, standardised prescription forms and documents to facilitate communication between caregivers too comprehensive for daily use; (2) not all patients received the information pack or support developed at the time of diagnosis; and (3) many patients did not consult a specialist physiotherapist or only did this post-operatively.

Our hypothesis was that a revision of the care pathway would improve quality of care, enhancing patient outcomes. The aim of this study was to assess the patient-perceived quality improvement after revising the care pathway between primary and hospital care.

Methods

Primary care in Belgiumis characterised by a network of many healthcare professionals, mainly working independently. Before this quality improvement initiative, there was no structural link between primary care and the hospital involved. The hospital, AZ Sint- Jan, treats almost 200 patients with radical prostatectomy each year.

All patients treated with a radical prostatectomy from the region of Bruges were included in the care pathway.

Developing, implementing and evaluating the care pathway was guided by an existing 30-step scenario.14 The changes introduced are presented in Figure 1.

Figure 1: Care pathway ’Radical prostatectomy across the continuum of primary and hospital care’

A multidisciplinary group was formed consisting of representatives of primary and hospital care to assist in the care pathway process. An ad-hoc working group met regularly to evaluate the care pathway and prepare for meetings of the multidisciplinary group.

Care pathways are complex interventions.1 Given the background of little evidence about the quality improvement effect of care pathways between primary and hospital care, an exploratory trial was performed to test the feasibility of quality measurement, the possible intervention effect and the recruitment.15 A pre–post-intervention postal survey was used.

Quality of care was translated into patient-perceived quality indicators.16,17 These were measured via a questionnaire. Two groups of patients received this postal questionnaire after the post-surgical consultation: one group before (pre-intervention) and another group after (post-intervention) implementation.

The questionnaire was developed based on: (1) experiences of patients with prostate cancer;18,19 (2) relevant parts of a similar existing questionnaire; 20 and (3) the ‘Patient Perceived Coordination Index’.21 The content validity ratio (CVR) was calculated. 22 The Distress Thermometer to measure well-being was integrated.23 Face and content validity were achieved.

Data were analysed using SAS V9.2. A Fisher’s exact test was used to compare differences for dichotomous variables, and a Mann–WhitneyU-test for ordinal and continuous variables.

Results

About 70% (46/67) of the patients in the pre-intervention group and 42% (46/109) of the patients in the post-intervention group were asked and consented to participate. All patients who consented to participate returned the completed questionnaire. The pre-intervention and post-intervention groups were comparable in terms of age and certain general practitioner (GP) characteristics (Table 1).

Table 1: Overview of patient characteristics

The scores for patient-perceived communication and co-ordination between caregivers were high both in the pre- and the post-intervention. No differences were found (Table 2).

Table 2: Patient perceived quality indicators

More patients in the post-intervention group received the information pack during the pre-operative consultation: 95.1% versus 81.0%. This difference was not significant after correcting for multiple testing.

Post-intervention, 86% of the patients consulted a physiotherapist specialising in PFME pre-operatively compared with 56% of the patients pre-intervention. This effect was not significant after correcting for multiple testing.

No patients in the post-intervention group experienced pain. There was no effect after correcting for multiple testing. No other effects were found.

Discussion

Given the scant evidence available on the effect of care pathways between primary and hospital care, this exploratory trial provides information about quality measurement, the possible intervention effect and the recruitment.

Because patient-centred care is becoming more important, greater efforts are being made to gather patients’ own quality assessments. Rather than measuring satisfaction, quality of care was translated into patient-perceived quality. Experience measures are less subjective and yield more detailed information for quality improvement than satisfaction measures.24

Quality was already perceived to be high before the care pathway was implemented. Teams performing at a lower quality level will benefit more, but are probably less likely to participate.25 This intervention effect can be used for sample size calculations.

The effect of the care pathway was also influenced by contextual factors.26,27 The factors that contributed to the success of this care pathway were: representation of all healthcare professionals involved, commitment of the ad-hoc working group, support available and the perceived need to change the current care processes among healthcare professionals involved (a bottom-up approach). Changes in key individuals in the ad-hoc working group, the major time investment, the need for information technology to support the care pathway and lack of physician leadership impeded implementation of this care pathway.

Patients were recruited by the specialist nurse. Not all patients were asked to participate, leading to a possible bias. All patients who consented to participate returned the completed questionnaire. The response rate will probably be lower in an experimental trial.

Quality improvement is a continuous process. This quality improvement project is currently at a critical crossroads.28 The danger of worsening care exists at this point, because there is no longer management support or (structured) contact between primary and hospital care. However, the improvement is still continuing as the hospital collaborates with a patient association to organise meetings to improve patients’ well-being. More than 80 patients participated in the first meeting. Meanwhile, other hospitals in the region have expressed interest in taking part in these meetings. The hospital is also exploring whether and how GPs could be involved postoperatively. In this way the quality improvement process is continuing.

Funding

The project was financed by the King Baudouin Foundation.

Ethical Approval

This study was approved by the Ethics Committee of the hospital involved. All patients signed an informed consent form.

Peer Review

Not commissioned; externally peer reviewed

Conflicts of Interest

None.

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