Summary

Objective: To evaluate the quality of anticipatory care in a 24-hour private hospital-based outpatient clinic by conducting a clinical audit on the practice of preventive care and screening.
Design: Clinical audit
Subjects: Medical records of active patients attending the clinic in the two-weeks periods of the two-phases audit were reviewed.
Main outcome measures : In the f ir s t phase, components of anticipatory care in different categories (i.e. immunization, cardiovascular risk screening, cancer scr eening and elder l y heal th) wer e anal yzed. Deficiencies were identified and changes were implemented. A second-phase record review was per formed 8 months af ter changes had been implemented. Components of anticipatory care provided and the number of abnormality detected by screening were compared in the two phases.
Results: Five hundred and thirty-three and 560 records were reviewed in phases one and two, respectively. There were improvements in most of the components of anticipatory care, including immunization status, BMI, smoking status and cessation advice, exercise habit and advice, lipid screening, diabetes screening, cervical cancer screening (Pap smear), breast cancer screening (mammography), colorectal cancer screening, fall risk factors screening, and visual and hearing impairment screening. More patients with weight problems, smoking habit, diabetes mellitus and hyperlipidaemia were found after changes were implemented. One case of CIN I and one case of colonic polyp were also detected through the screening.
Conclusion: The first audit revealed there were unsatisfactory standards of anticipatory care in the author’s clinic. This deficiency in care was mainly attributable to ineffective time management and documentation. The audit exercise led to changes that had a significant impact on the process performance and increased detection of abnormalities, which could contribute to improved outcome and better prevention of diseases.
Keywords: Audit, Anticipatory care, Disease prevention

摘要

目的：在一所廿四小時運作的私家醫院門診部進行臨床審計， 評估它在預防和篩查疾病上的預見性監護質素。
設計：臨床審計
對象：分別在兩個階段進行為期兩週的檢閱求診者病歷記錄。 主要測量內容：在第一階段，分析病歷中預見性監護方面的各 項目。（如疫苗注射，心血管危險因素篩查，癌症篩查和老人 健康）。確認不足之處，然後進行改善。在改善八個月後，進 行第二階段同類型檢閱。比較在這兩階段中所提供的預見性監 護項目和從中被篩查為異常的次數。
結果：在第一和第二階段中，分別檢閱了533和560份病歷。 多數預見性監護項目都得到改善，包括疫苗注射狀況，體重質 量指數，抽煙狀況和戒煙忠告，運動習慣和忠告，血脂、糖尿 病、子宮頸癌（帕氏塗片）、乳癌（乳房X線造影、大腸癌， 跌倒危險因素，視聽能力的篩查。經改善後，有較多體重問 題，嗜煙，糖尿病和高脂血症的病人被確認。此外，還有一例 前期子宮頸癌變和一例腸息肉被發現。
結論：在第一次審計，顯露作者診所在預見性監護方面的不 足，其主要原因是缺乏有效率的時間管理和在文件上的記錄。 經審計後進行改變，改善了實務上的成果和更易察覺病人健康 上的變化，對疾病預防和改善治療結果有重要的意義。
主要詞彙：審計，預見性監護，疾病預防

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Background

Anticipatory care includes all measures that aim at promoting good health and preventing or delaying the onset of diseases or their complications. It incorporates both health promotion and disease prevention. Health promotion is a process of enabling individuals to have increased control over their own health and to improve it.

Disease prevention involves identifying and reducing specific risk factors. The aims of health promotion and disease prevention are to improve the quality of life, reduce the burden of premature disability and increase life expectancy of a population.¹

Opportunistic anticipatory care is one essential task for family doctors during a consultation. According to Stott and Dav is,² “One of the mo st exc itin g and controversial components of every consultation is the opportunity it provides for both the promotion of healthy lifestyles and early or pre-symptomatic diagnosis”. Prevention is the best cure. There is clear evidence that many preventive activities do reduce the morbidity and mortality associated with a number of diseases, including infectious disease, cardiovascular disease, malignancy, etc.³ It is therefore worthwhile to promote the practice of anticipatory care.

Anticipatory care is best carried out by family doctors – family physicians or general practitioners. Firstly, the holistic and comprehensive nature of care in family practice provides an ideal opportunity for effective preventive action. A close doctor-patient relationship influences the patient’s compliance in both treatment and preventive advice. Besides, the continuity of care in family p rac ti ce is one pa ramoun t fou nda tio n for preventive care and lifestyle modification. General practitioners (family doctors) have been described by Gray and Fowler as “the key to preventive medicine”.⁴

Anticipatory care is an evidence-based practice. There are several well-es tablished guidel ines for anticipatory care, including the Guidelines for Preventive Activities in General Practice (RACGP, Australia),⁵ Guide to Clinical Preventive Service (the US Preventive Service Task Force),⁶ the Canadian Guide to Clinical Preventive Health Care (The Canadian Task Force on the Periodic Health Examination),⁷ Policy Recommendations for Periodic Health Examinations of the American Academy of Family Physicians,⁸ the CDC Preventive Guideline,⁹ etc. With such strong evidence support, family doctors should therefore take every opportunity to provide anticipatory care at every consultation.

The author works as a Resident Medical Officer in a 24-hour private hospital-based outpatient clinic in a group practice, where episodic urgent care is traditionally the major care provided. Clinical audit is an important means of quality assurance. It is a process of critically and systematically assessing our own professional activities with the commitment to improve personal performance, and ultimately the quality and cost-effectiveness of patient care.^10,11 With strong support from the hospital and increasing demand for family medicine services from the public, the author decided to perform a clinical audit on the practice of anticipatory care. It is hoped that clinical audit would help to promote the culture of family practice in the clinic, especially the practices of health promotion and disease prevention.

Objectives

1. To carry out an audit on the practice of anticipatory care;
2. To id e n t i fy d e f i c i e n c i e s in th e s t an d a rd o f anticipatory care;
3. To implement changes to improve the standard of care; and
4. To evaluate the impact of the change on patient care.

Methodology

Justification of audit criteria

In Hong Kong, there is no agreed guideline from any authoritative bodies on what is worth doing an audit. The author, therefore, used the criteria in accordance to the Royal Australian College of General Practitioners’s (RACGP) Guideline for Preventive Activities in General Practice,³ as it is easy to read and to follow. Besides, the author, like most Family Medicine’s trainees in Hong Kong, is a Fellow of the Royal Australian College of General Practice. It is better to stick with this Guideline as it has been shown to have good validity & reliability. The criteria focuses on child, women and elderly health, cardiovascular risk factor screening and cancer screening, which are of relevance, appropriate and important in any primary care clinic.

Th e f ir s t c r i t e rio n i s th e d o c ume n t a tio n o f vaccination, like the flu vaccine, hepatitis vaccine, childhood routine vaccination, etc, which is important because immunization is a worthwhile and effective measure for disease prevention.

Criteria 2 to 7 are related to cardiovascular risk factors. According to a study by the Chinese University of Hong Kong, a body mass index of 23.0 – 24.9 kg/m² and ³ 25 kg/m2 was associated with a 3.1-fold and a 5-fold in c r e as e in c a rd io v as c u l a r r i s k , r e s p e c t i v e ly. ^{1 2} Hypertension itself accounted for more than 8,000 hospital admissions in 2000.¹³ Another observational study found that a moderate to high level of physical activity reduced coronary heart disease and stroke.14 In ad dition, systematic reviews have found that reducing cholesterol levels in asymptomatic individuals lowers the incidence of cardiovascular events.¹⁴ The importance of managing cardiovascular risk factors in reducing cardiovascular mortality and morbidity has been confirmed by numerous studies. It is obviously worthwhile to audit family doctors on their performance of opportunistic health promotion and education for the purpose of reducing cardiovascular risk.

Criteria 8 to 9 are related to cancer screening of at risk populations. Cervical cancer screening has been shown to be successful because it satisfies all Wilson’s principles on screening.¹⁵ Regular mammography screening has been shown by randomized controlled trials to reduce breast cancer mortality.¹⁶ A meta-analysis of mortality results from randomized controlled trials showed that those patients allocated to receive faecal occult blood test screening had a reduction in colorectal cancer mortality of 16% (RR 0.84, CI: 0.77 – 0.93).¹⁷

Criteria 11-13 are related to screening in the elderly. There is increasing prevalence of geriatric conditions which need to be taken care of by family doctors. Assessments of risk factors for fall, and visual and hearing impairment were chosen because these are important and relatively easy to do.

Outcome indicators were not included in this audit because significant improvement in disease prevention and health promotion might require a long cycle time, which was not feasible in this audit.

Justification of audit standards

The standards were defined according to the levels of recommendation from RACGP (Table 1). For the criteria (8 out of 13) with recommendation A, the target standard was set at 100% as all of them are important and easy to implement. For example, it is easy for d o c t o r s t o e n q u i r e , ad v i c e o n an d d o c ume n t immunization status, as well as smoking and exercise habit. The level of performance in cancer screening was measured according to whether the doctor had ad vi se d or r ec ommen de d th e sc ree ning t es t (Pap smear, mammograghy, stool for faecal occult blood test or colo noscopy), and whether th e advice was documented.

The target standard for the remaining criteria (except lipid screening) was set at 70%, as it may not be easy and realistic to carry out these screening tests, like checking fasting blood sugar, visual and hearing impairment screening tests on every patient because these may need much extra time, and incur additional costs to the patients. A standard of 50% was set for lipid disorder screening because such practice is still controversial.

Data collection

Medical records of patients’ consultations during the two audit periods (December 1^st to 12^th 2003 and September 1^st to 14^th 2004) were reviewed. The audit samples were active patients who had been attending the clinic for more than 1 year and consulted the same doctor for at least three times, although not necessarily consecutively. Cases of trauma, emergency conditions and attendance for administrative reasons were excluded.

All data were recorded on the data collection form (Appendix 1) by the author, with assistance from nurses and clerical staff. The first-cycle audit results were presented at the practice meeting in April 2004. Reasons for deficiencies were identified and discussed. All doctors, nurses and staff were alerted on the areas of deficiencies. Suggestions were proposed, and strategies for improvement were agreed upon and implemented from April to September 2004. The second-cycle audit data were collected in September 2004.

Statistical method

The results of the two phases were compared and analyzed by SPSS. The Chi-square test was used to test the difference between the two phases. The null hypothesis is that there is no difference between the level of performance in the first and second phases. If the p value is less than 0.05, the difference would be statistically significant.

Results

Patient characteristics

Five hundred and thirty-three and 560 records were reviewed in the first and second phases, respectively (Table 2). The majority of the patients (1^st phase: 49.7%; 2^nd phase: 56.3%) were between the ages of 18 to 45 years. There were slightly more female patients than male patients in both phases (1^st phase: 52.9%; 2^nd phase: 59.8%). More than three quarters of patients (1^st phase: 83.6%; 2^nd phase: 79.4%) were not suffering from any chronic d isease, such as cardiovascular d isorder, malignancy, etc.

Process performance

The first-cycle audit revealed a suboptimal standard in the practice of anticipatory care (Table 3). Reasons for def icien cies (Tabl e 4) and agre ed s tra tegi es for improvements (Table 5) were proposed. The results of process performance and test abnormalities detected in the two phases are shown in Table 3 and 6 respectively. There were significant improvements in all criteria (except blood pressure measurement), but the majority were not up to the target standard.

Discussion

Patient characteristics

The age and sex distribution of the samples in the two phases showed statistically significant difference but should not have affected the results because anticipatory care should be applicable to all ages and both genders.

The gender distribution was quite even, with slightly more females. Age distribution was reasonable with more than half of the population being in the range of 18 to 45 years old. Most of them were working and educated, and could financially afford to consult private practitioners. Because of their sedentary lifestyle and stressful life, they were a group which should benefit most from getting appropriate anticipatory care. The majority of them did not suffer from chronic disease that would require regular check up and follow up.

Process performance and impact of care

The aim of anticipatory care is health promotion and disease prevention. Health promotion is an active process that family doctors are routinely performing everyday. By providing more anticipatory care, the objective of health promotion would obviously be better achieved. For disease prevention, it usually takes a substantially longer period of time and a large number of subjects for any impact o n the final outc ome to be demon strated. However, the rate of detection of abnormalities can be u se d as a s u r ro g a te o ut c ome for meas u rin g th e effectiveness of disease prevention.

Th is a u di t d et e c t ed an in c r e as e d numb e r o f smokers, patients who were overweight or obese, and patients who had diabetes or hyperlipidaemia. Such findings would lead to better management of their cardiovascular risks. In addition, one case of CIN I was found from Pap smear, and one case of colonic polyp was found from faecal occult blood test followed by subsequent colonoscopy. In this audit, 86 (1^st phase: 9 out of 208 patient; 2^nd phase: 77 out of 270 patient) eligible patients had been screened by Pap smear test, and one case of CIN I was detected; the impact on disease prevention appeared minimal. However, the impact will increase with continuing the audit spiral process on patient care.

Case detection rates might not be accurate because of inadequate documentation and the limited sensitivity of scr eening. However, th ese resu lts sugg est an increased number of abnormalities which could be detected by providing more active anticipatory care. He nc e, it i s e xp ect ed th at more abno rmal case s, hopefully cu rable diseases, would be detected by continuing the practice of anticipatory care.

Limitation

The implementation of the change process was relatively short due to time limitation of the study. Th e f ig u r e s i n th e s t an d a rd s ac h i e v e d ma y b e u n d e r es t ima t e d b ec a u s e an t i c ip a to ry c a r e mig h t a c t u a l l y h a v e b e e n p e r fo rme d wi t h o u t b e i n g documented, probably as a result of time pressure. Besides, it is always difficult to differentiate medical records in which documented activities were regarded as an ticipato ry care from tho se regarded as o ther management activities (e.g. case finding, diagnostic test or part of the p atient managemen t). Fin ally, follow-up actions were not assessed properly in this project.

Conclusion

Ant i c ip a to ry c a r e i s an e s se n t ia l el eme n t in f a m i l y p r a c t i c e , b u t i s a l s o c o m m o n l y underperformed. With changing epidemiology and patient expectation, health promotion and disease pr eve ntio n s hou ld b e s tre ngthene d. Th roug h the p r o c e s s o f c l in i c a l a u d i t , q u a l i ty as s u r an c e i s promoted. A definite impact on patient care has been demonstrated. Subsequent studies focusing more on the outcome criteria would provide a better guide for the evaluation of the effectiveness of the practice of anticipatory care. Moreover, audit of anticipatory care should be a continuous and spiral process. It serves as an important framework for the development o f o th e r c l in ic a l au d i t an d pro to co l s with in th e practice, from which good practice and standard of care could be maintained.

Acknowledgement

The a uthor wo uld like to expres s his sincere gratitude to the hospital management committee and all staff of the outpatient department and the information technology department of the Hong Kong Sanatorium & Hospital for their continuous support throughout the a u d i t p ro j e c t , an d to Pro f e s s o r Cin d y Lam an d Dr Eileen Tse for their expert advice.

Key messages

1. Opportunis tic anticipatory ca re is one of the essential tasks of the family doctor during a consultation.
2. Deficiency of care in the practice of anticipatory care was found in this study. The main reasons we r e i n e f f e c t iv e t ime man a g eme n t an d documentation in a consultation.
3. Clinical audit is effective in improving process of care in anticipatory care.
4. The impact of the audit on disease prevention and early treatment would be more significant with continuation of the audit spiral process.

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Reference

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