Press releases Monday 25 May to Friday 29 May 2009
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(1) Study questions impact of GP pay incentives on patient care
(2) Culture change to encourage whistleblowing needed, says expert
(3) Videos help elderly patients plan end of life care
(1) Study questions impact of GP pay incentives on patient care
(Research: Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1870
The care of patients with diabetes has improved over the last decade, but this does not seem to be a direct result of the quality and outcomes framework – the scheme that rewards UK general practices for delivering quality care.
The scheme in its present form may even lead to reduced levels of care for some patients, say researchers in a paper published on bmj.com today.
The quality and outcomes framework was introduced in 2004 to improve standards of primary care by linking financial incentives to performance indicators for all general practitioners in the UK. The management of diabetes includes targets for controlling blood pressure, cholesterol and blood glucose levels. Payments are staged and are subject to minimum and maximum thresholds.
Since its introduction, a series of studies have suggested an improvement in the management of people with diabetes in primary care, but it is unclear whether this is a direct result of the scheme or reflects existing trends in response to other quality improvement strategies.
So researchers based at the Universities of Birmingham and Manchester assessed the proportion of patients meeting diabetes targets annually between 2001 and 2007 (three years prior to and following the introduction of the scheme). Their analysis included 147 general practices covering over one million patients across the UK.
They found significant improvements in all of the diabetes targets over the six year period, with consecutive annual improvements observed before the introduction of incentives.
However, these improvements in care appear to plateau after the introduction of the framework.
This could reflect the increasing difficulty of target attainment in poorly controlled patients, say the authors. However, it may also reflect the lack of further incentive after attainment of the upper payment thresholds (the ceiling effect).
If so, they suggest that upper thresholds may need to be removed or targets made more challenging if people are to benefit.
Another important finding was that up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes were not captured in the framework assessment. This needs to be addressed to reduce health inequalities, say the authors.
Our work and that of others highlights the potential unintended consequences of the scheme and raises concerns that the quality and outcomes framework may not have been as efficient in reducing inequalities in health in diabetes as was hoped, write the authors.
Although the management of patients with diabetes has improved since the late 1990s, the impact of the pay-for-performance initiative on care is not straightforward, they conclude.
Contacts:
Dr Melanie Calvert, via Anna Mitchell, University of Birmingham Press Office
Email: a.i.mitchell@bham.ac.uk
(2) Culture change to encourage whistleblowing needed, says expert
(Editorial: Changing the face of whistleblowing)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2090
Greater statutory protection, support from regulatory bodies and, above all, a culture change to encourage whistleblowing are required to protect patients and clinicians, according to an editorial published on bmj.com today. A decade after an anaesthetist exposed avoidable deaths in children having heart surgery at Bristol Royal Infirmary, whistleblowing is still hazardous, writes Peter Gooderham from Cardiff Law School. Yet most patients would surely expect doctors to protect them from potential harm and the General Medical Council - the doctors’ regulatory body - stipulates a professional ethical duty to raise concerns. An NHS doctor is likely to have a contractual duty to participate in clinical governance procedures, which should include systems for raising concerns, and guidance on how to proceed when appropriate action is not taken, explains the author. Yet whistleblowers may be made to feel that they are the problem and may even find themselves the subject of retaliatory complaints and disciplinary action. For example, the Bristol whistleblower’s concerns were “cavalierly dismissed,” his career stalled, and he now works on the other side of the world. Limited protection for whistleblowers is afforded by the Public Interest Disclosure Act 1998, but some believe that this protection is inadequate, and that it did not help the Bristol whistleblower. Furthermore, during the recent investigation into poor standards of care at Staffordshire General Hospital, staff were criticised for operating a “culture of silence.” But Gooderham believes that such criticisms “may worsen the situation by exacerbating a culture not just of silence, but of fear.” Professional people may feel damned if they do raise concerns, and damned if they don’t, he says. He believes several measures should be considered, including greater statutory protection, more support from regulatory bodies and, above all, a culture change to encourage whistleblowing. A start would be for those in official positions to recognise the risks of whistleblowing. Then they might begin to limit the damage wrought by the next scandals which are probably already happening, he concludes.
Contact:
Peter Gooderham, Associate Tutor, Cardiff Law School, Cardiff, UK
Email: GooderhamEP@Cardiff.ac.uk
(3) Videos help elderly patients plan end of life care
(Research: Video decision support tool for advance care planning in dementia: randomised controlled trial)
http://www.bmj.com/cgi/doi/10.1136/bmj.b2159
Video images of advanced dementia can help patients choose the type of care they want in the future, finds a study published on bmj.com today. The images also led to more stable treatment preferences over time.
Respecting patients’ preferences for treatment is a key component of high quality end of life care. Traditionally, doctors help patients engage in advance care planning by describing hypothetical situations, such as advanced dementia, and exploring possible goals of care, but this approach is limited.
Visual images have been shown to improve communication of complex health information and inform end of life decision-making. So a research team, led by Angelo Volandes at Massachusetts General Hospital, examined whether a video of a patient with advanced dementia could shape the choices made by patients about the kind of care they would want in the future.
The study involved 200 healthy people aged 65 years or above and living in the community. Background data such as age, race, sex, educational status, and marital status was recorded.
Patients were interviewed about their health and scored on their knowledge of advanced dementia before being randomly split into two groups; listening to a verbal narrative describing advanced dementia (control group) or listening to the same verbal narrative followed by watching a two minute video depicting a patient with advanced dementia (intervention group).
Participants were then interviewed again about their knowledge of advanced dementia, preferences for goals of care and, for the intervention group, their comfort with the video decision support tool.
There were three options for preferences for goals of care: life prolonging care (prolonging life at any cost), limited care (aiming to maintain physical functioning), and comfort care (aiming to maximise comfort and to relieve pain).
Among the 106 patients receiving only the verbal narrative, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain of their preferences. Among the 94 patients who also saw the video, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain of her preferences.
Thus a significantly greater proportion of participants in the video group opted for comfort care. Those opting for comfort care were also more likely to be white, a college graduate or higher, in good health, and have greater health literacy.
Mean knowledge scores were also significantly higher in the video group compared to the control group.
After six weeks, participants were contacted again to see whether their preferences had changed. Among the 94 (89%) in the control group who could be contacted, 27 (29%) changed their preferences, while among the 84 (89%) participants contacted in the video group, five (6%) changed their preferences.
The video decision support tool was also highly acceptable to participants.
When presented with the possibility of developing advanced dementia, older patients living in the community are more likely to choose comfort as the primary goal of care after viewing a video of a patient with the disease and listening to a verbal description rather than just hearing a verbal description of advanced dementia, say the authors.
Viewing the video also improved knowledge of advanced dementia and enhanced stability of preferences for treatment over time compared with hearing only the verbal narrative.
We have shown that video decision support tools enhance elderly patients’ decision making by ensuring that it is both more informed and consistent over time, conclude the authors. And they suggest that future work may extend the use of video decision support tools to other disease areas, such as advanced cancer.
Contact:
Angelo Volandes, via Sue McGreevey, Public Affairs Office, Massachusetts General Hospital, Boston, MA, USA
Email: smcgreevey@partners.org
For more information please contact:
Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bmj.com
Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
British Medical Association
BMA House, Tavistock Square, London WC1H 9JP
and from:
the EurekAlert website, run by the
American Association for the Advancement of Science (http://www.eurekalert.org)
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