1. Using research to inform and change primary care Professor James Dunbar Greater Green Triangle UDRH jamesdunbar@flinders.edu.au

2. Males: 143,821 YLD 44% of total DALYs Cardiovascular 10% Cancer 8% Mental disorders 25% Chronic respiratory 10% Injuries 6% Musculo- skeletal 6% Diabetes 4% Other 15% Neurological 16% Females: 147,229 YLD 50% of total DALYs Cardiovascular 7%Cancer 7% Mental disorders 28% Neurological 18% Chronic respiratory 9% Injuries 3% Musculo- skeletal 10% Diabetes 4% Other 14% Years Lost Due to Disability (YLD) by sex and disease group, Victoria 1996

3. Areas with high and low DALY rates: Heart disease and diabetes high low

4. New Challenges for Better Health by 2010 Lifestyle and behaviours are key contributors to health and disease patterns

5. What is the research question?

6. What is the research method?

7. Levels of evidence l A meta-analysis, systematic review or RCTs l Bcase control or cohort studies l Cextrapolated from case control cohort studies l Dcase reports or expert opinion

8. EBM – the fallacy l General practice is holistic l Absence of evidence is not evidence of absence l Who pays? l Common sense and experts l Selective publication and publication bias l Lifestyle risk factors and population approaches

9. 0 60 20 40 60 40 20 0 120140160180200100 Systolic BP 0 40 30 20 10 Risk % Prevalence % BP distribution, risk for coronary heart disease or stroke, and number of such morbid events in relation to blood pressure during 13.5 years’ follow-up of 855 men aged 50 at entry. Wilhelmsen BP distribution Morbid events Risk Morbid events n

10. MORTALITY CHANGES IN NORTH KARELIA IN 25 YEARS. (35 - 64. AGE ADJUSTED, MEN) MORTALITY RATE IN CHANGE 1970 (PER 100 000) IN 25 YEARS (%) TOTAL 1556 - 45 ALL CVD 912 - 68 CORONARY 695 - 73 CANCER 293 - 45 LUNG Ca. 167 - 71

11. RISK FACTOR CHANGES IN NORTH KARELIA 1972 AND 1992 AGE 25-59 Male Female Smoking S-cholesterol Blood Pressure % mmol/l mmHg % mmol/l mmHg 52 6.9 149/92 10 6.8 153/92 32 5.8 142/85 17 5.6 135/80

12. EBM – the fallacy l General practice is holistic l Absence of evidence is not evidence of absence l Common sense and experts l Selective publication and publication bias l Lifestyle risk factors and population level l Economic evidence, patients’ views and implementation

13. Evidence of Cost Effectiveness Patient Priorities & Satisfaction Evidence of Effective Service Delivery Evidence of Clinical Effectiveness Identify gaps in Research and Development Effective Healthcare

14. ‘Evidence’ in CVD l Prava- or simvastatin l Other choice of drug l Dietary advice

15. Publishing quality improvement l Context l Outline of problem l Key measures of improvement l Process for gathering information l Analysis and interpretation l Strategy for change l Effects of change l Next steps

16. Change Not all change is improvement, but all improvement is change Real improvement comes from changing systems not changing within systems To make improvements we must be clear about what we are trying to accomplish, how we will know that change has led to improvement and what change we can make that will result in improvement The more specific the aim the more likely the improvement

17. Concentrate on meeting the needs of patients rather than the needs of organisations Measurement is the best for learning rather than for selection, reward or punishment Effective leaders challenge the status quo by insisting that the current system cannot remain and by offering clear ideas about superior alternatives

18. Fundamental Questions for Improvement l What are we trying to accomplish? l How will we know that a change is an improvement? l What changes can we make that will result in improvement?

19. Fundamental Questions for Improvement l What are we trying to accomplish? AIM

20. Fundamental Questions for Improvement l How will we know that a change is an improvement? MEASUREMENT All change does not lead to improvement, but all improvement requires change

21. Fundamental Questions for Improvement l What changes can we make that will result in an improvement? CHANGE IDEAS

22. Model for improvement l What are we trying to accomplish? l How will we know that a change is an improvement? l What changes can we make that will result in an improvement? Act Plan Study Do

23. Incremental improvement Time Performance low investment per project (small projects, but in large numbers) grass roots based; empowering (builds morale, customer satisfaction) needs reward and recognition system (reinforces improvement vision) 100% workforce participation

24. Secondary Prevention of Coronary Vascular Disease An Example of Improvement

25. CVD Project l Involved 105 GPs in 37 practices l All data shared unanonymously l Chosen as a model later applied to diabetes and hypertension l Became multidisciplinary

26. AIM: the original project Improve Secondary Prevention of CHD by developing and introducing a local guideline and auditing clinical management before and after introduction.

27. Lifestyle l Smoking Habits –19% (n=191) current smokers –Only 3 on Nicotine Replacement Therapy –On re-audit, rate down 1% (0-31%)

28. Lifestyle l 66% (n=702) received dietary advice at least once l On reaudit increased to 73%

29. Secondary prevention project: current components l Re-audit of practice activity December l Patient-held record card l Resources pack l Introduction and evaluation of Heartscore patient-interactive software l NURSE TRAINING

30. Cholesterol & Statins

31. Blood Pressure 31 % (n=302) diagnosed with Hypertension

32. Aspirin

33. Professions involved in training l dietician l diabetic physician, cardiologist, rehab. medicine specialist l general practitioners l health promotion staff l physiotherapist l pharmacist

34. Nurse training l Behaviour change skills (2 Days) l Smoking cessation l Diet and statin drugs to lower cholesterol l physical activity and angina management l diabetes/ hypertension l clinic management

35. Main outcomes l 10% reduction in admissions in first year

36. Peer Review l Facilitated inter-practice groups l collegiate approach l provided with good information l protected time