Les Toop and Education Dept Pegasus Health and Department of Public Health & General Practice

1. Optimising Patient Care by managing variation in clinical practice: (Do it yourself, or have it done to you). Les Toop and Education Dept Pegasus Health and Department of Public Health & General Practice University of Otago, Christchurch,

2. There is a foolish corner in the brain of the wisest man Aristiotle c 370BC

3. Why is clinical variation important? • It provides the setting both for innovation and for patients and clinicians to make a variety of decisions • However it appears to exists in most parts of the health system to a degree that defies rational explanation • For interventions with potential benefit, the degree of variation probably reflects both under and over treatment / investigation

4. Variation in clinical practice Over utilisation Under utilisation Healthy variation

5. Sometimes interpretation is difficult! Variation may be understandable

6. Or Variation may seem too extreme to be rational

7. Reducing variation in clinical practice Over treatment avoided Unmet need addressed Healthy variation

8. IF UU<OU, rational use is promoted whilst freeing up resources for other uses, win - win UU OU Under utilisation (UU) Healthy variation Over utilisation (OU)

9. BMJ head to head on clinical variation In the absence of compelling evidence, different prior beliefs are rational and differences in practice do not offer a disservice to patients. They are therefore not inequitable RJ Lilford BMJ 2009;339:b4809

10. Stephen Richards reply “A large amount of current variation remains unwarranted. Only by explaining the variation can we expect to improve quality and cost effectiveness. Yet knowing the cause of variation is only the first battle; the second is to convert that knowledge into action” BMJ 2009;339

11. “The need is not so much for payers and regulators to force the medical system into uniformity . . . but rather for the profession and its leaders to recognize that there is embedded in this cacophony of practice so much waste and hazard that physicians simply owe it to themselves to reduce the variation wherever they can Berwick. DM Med Care 1991;29:1212-25

12. Pegasus edn the beginnings • A Perceived need • Enthusiasm (optimism of youth?) • Opportunity (policy vacuum) • A willing funder • A belief in a model (post PreMeC) • An incentive • Organised General Practice

13. The likely lads 19 years ago

14. Martin Seers, Les Toop, Graham McGeoch, Chris Leathart, c 1992 all in their 30’s

15. Pegasus Mission Statement 1992 Finite resources Best practice “The promotion of best clinical practice with optimal and ethical use of finite resources”

16. Our patients deserve well educated, up to date, reflective and critically thinking clinicians who have the time and ability to discuss currently understood evidence, including its inherent uncertainties, and assist in informed decision making…..

17. Our Hypotheses in 1992 • Doctors will practice rationally if given independent evidence, feedback , the opportunity to discuss with peers and appropriate incentives( a la PreMeC) • Rational practice will result in efficiencies • Current methods were insufficient to counter effective and sophisticated marketing from industry which was driving expenditure growth • National safety alerts and information on new technologies were and remain inadequate

18. Essential ingredients (1992) • Multi faceted approach, must feel safe • Feedback essential • Ownership of education methods and content by learners crucial • Guidance rather than guidelines reinforces professional educational approach • Develop in house evidence review and analytical capacity (team of 10 in 2011)

19. Peg Health Core Education Team Facilitators 2010

20. The Growth of Interdisciplinary Education • 1993 (5) to present, 90 % engagement of General Practitioners in Greater Christchurch engaged in peer led small group education - currently 20 groups of approx 15 – 20 • In 2000, joined by practice nurses, currently > 90% engagement - now 18 small groups • In 2010, joined by pharmacists now 13 groups -more than 200 from around Canterbury • 2011 Physiotherapy joins in with falls education

21. The Process • Monitor utilisation for changes • Monitor changes in evidence / availability • Clinical reference group needed to interpret and seek further data, iterative process • Decide if situation suitable for intervention • Choose most appropriate learning environment • Monitor effect of intervention

22. A recent example of best vs actual practice dissonance

24. Might this be a problem? • Smaller tablet size - likely off label use • Metabolic side effects worrisome • Becoming recreational drug of abuse overseas • Who is using it and for what? • Why is the rate of growth so steep?

25. Growth in Quetiapine Dispensingsby tablet strength Partnership Health GP data

26. Pattern of Quetiapine Prescribing • Elderly are the group dispensed the most quetiapine by unit volume overall (this is mostly made up of 25mg tabs), followed by 35-44y olds • Highest growth in prescribing (by units dispensed) is seen in the 45-54y age band who are also 3rd highest total users Data for Partnership Health GPs

27. Unique patients on Quetiapine per Partnership Health GP (1/7/09-31/12/09) 75thCentile GP = 12 patients Median GP = 6 patients 25thCentile GP = 3 patients Individual Partnership Health affiliated GPs (each diamond represents a single GP) 380 GPs represented (includes locums and registrars), 3638 total patients dispensed quetiapine for this time period

28. The plan • Pre reading • Case based interactive small group ed session • Focus on licensed and unlicensed use • Feedback on quetiapine prescribing • Group discussion of appropriate use and reasons for growth • Post reading • Monitor usage

29. Steps to an effective small group education meeting

31. Pegasus HealthGP Small Group EducationMay 2010 Atypical Antipsychotics

34. Often other issues are uncovered

35. Quetiapine + Antidepressant Use CDHB-wide Primary Care data

36. Early evaluation showed effectiveness • First four groups, first four topics, acted as own controls, seasonally adjusted • Richards,(now Mangin) Toop et al Family Practice. 2003;20(2):199-206

37. Doubt is not a pleasant condition but certainty is absurd Voltaire