16 OPINION
PBS listed for COPD † & severe asthma ‡ 1
16 OPINION
10 MAY 2024 ausdoc . com . au
What happens to Maria ? Why you can ’ t measure GPs using CPD audits
PBS listed for COPD † & severe asthma ‡ 1
†
Trimbow 100 is indicated for the maintenance treatment of patients with moderate to severe COPD who are not adequately treated by a combination of an ICS + LABA or a LABA + LAMA . 2
‡
Trimbow 200 is indicated for the maintenance treatment of asthma , in adults not adequately controlled with a maintenance combination of a high dose of ICS / LABA , and who experienced ≥1 exacerbations in the previous year . 2
PBS
LISTED FOR COPD 1 †
PBS Information : Authority required ( STREAMLINED ). Severe Asthma ( 200 / 6 / 10 mcg presentation only ). Chronic Obstructive Pulmonary Disease ( 100 / 6 / 10 mcg presentation only ). Criteria Apply . Refer to PBS for full information .
Please review Product Information before prescribing . Product Information can be accessed by calling Chiesi Australia Medical Information on 1800 943 587 or scanning the QR code .
References : 1 . Pharmaceutical Benefits Scheme ( PBS ). Available at : www . pbs . gov . au . 2 . Approved Trimbow Product Information . Chiesi Australia Pty Ltd , Hawthorn East , VIC . 3123 . Tel : + 61 3 9077 4486 ; Email : medinfo . au @ chiesi . com ; Website : www . chiesi . com . au . Copyright © Chiesi 2024 . All rights reserved . Date of preparation : February 2024 . AU-TRI-2400014 . CHIE00168 .
PAGE 14 healthcare outcomes along with the less lofty goal of driving profits for shareholders .
Governments have an interest in harvesting primary care data because , in theory , it can be used to drive rationalised health policy through reductions in unnecessary prescriptions , pathology tests and diagnostic images .
But this is a deceptively simplistic way for governments to measure performance in the real-world health sector they fund .
A problem like Maria
Maria , by contrast , is invisible . She is invisible to policymakers , researchers , data and governance .
She is in her 50s and has multiple chronic illnesses . She is poor and , as a single mum in a rural town , has unstable employment .
She drinks too much , exercises too little , is overweight and has type 2 diabetes . Her English literacy , health literacy and digital literacy are poor .
She is also a carer , which means that she and her family survive on Centrelink payments .
As such , it is a constant struggle to keep a roof over her head and food on the table .
She has a history of intergenerational trauma , childhood trauma and medical trauma .
She is highly distrusting of health professionals , who in the past have missed major illnesses , dismissing her as “ anxious ”.
To put this another way , her HbA1c results are not her main concern . Dr Jane sees a lot of people like Maria . She works in a regional centre with some allied health and nursing services in the practice , but mostly she uses bespoke teams of allied health and nursing from the community when she can .
She is the ‘ lady doctor ’ in the practice , and the receptionists tend to suggest people like Maria see Dr Jane .
Her average consultation length is closer to 40 minutes .
As a result of this selection bias ( and the inbuilt misogyny of Medicare ), she brings in $ 250,000 a year .
Unlike Dr Tom , she cannot afford contemporary data systems to prove her worth to the funders .
Maria ’ s evidence
I have talked about outliers . But in reality , there are a lot of people like Maria in Australia .
Multimorbidity and mental health conditions are common after all , and so too is poverty .
But it is difficult to measure outcomes that are valid and applicable to populations containing patients like Maria because so many of the genuine outcomes are qualitative .
But even when it comes to numbercrunching , there is little evidence that is relevant to Maria because she is likely to be excluded from trials .
She is too complex , too multimorbid , too mentally unwell , too rural , too poor , too illiterate and too multi-factorial to generate the clean metrics that make it into the hospitals , the trials , the guidelines .
Dr Jane cannot base an assessment of her care of Maria on the guidelines built for Norm .
It would be like applying renal guidelines to heart transplants .
Dr Jane ’ s evidence
Dr Jane cannot refer Maria anywhere . Maria cannot afford allied health . And the hospital sees Maria as a ‘ frequent flyer ’ who is better managed in primary care .
Dr Jane has referred Maria a few times for various symptoms , but she has always been rejected from the public system .
Dr Jane does not believe that adherence to guidelines improves care for Maria because the guidelines intersect and contradict each other .
And anyway , Maria cannot afford the interventions and does not have the energy , resources or time to implement them .
Dr Jane does what all good GPs do , and focuses on the evidence-based medicine triad , synthesising best evidence with patient preference and medical opinion .
But none of this is easily captured in an audit .
If she decides to do it anyway , her performance will be compared against Norm ’ s guidelines for a single disease , using Norm ’ s metrics .
Yet Maria is unlikely to get better care from guidelines adherence because focusing on a measurable outcome like HbA1c or similar to measure quality of care is spectacularly inappropriate for patients like Maria and doctors like Jane .
Dr Jane will still have to use these metrics , because otherwise she will have trouble meeting her measuring outcomes obligations for CPD through ‘ gold standard ’ audits .
The end result is that regulators may well assume that Dr Jane is not achieving the same outcomes as Dr Tom and is therefore ‘ failing ’ to manage her patients appropriately .
The problem is that there is pressure on all of us GPs to work more like Dr Tom , decreasing the time of consultation and driving protocol-based care .
It is a disaster for Maria . It is also demoralising for Dr Jane .
How do we solve a problem like Maria ?
All interventions have benefits , side effects , contraindications and interactions . Health services are no different .
There is a perfect storm of interventions from governments , data industries , primary health networks , economists and regulators that work for Tom and Norm , but make things harder for Jane and Maria . These include :
• Compulsory audits in CPD
• The nudges towards protocol-based or guideline-based care
• The measurement of quality using guideline-based metrics
• The investment in data generation
• The dis-privileging of ‘ slow medicine ’ in the MBS
• The hierarchy of evidence that drives investment in randomised controlled trials . I am sure GPs like Dr Jane want to know that their performance is “ up to scratch ”.
I just don ’ t believe that the tool is an audit .
Looking at the data and measuring what happens in your practice is not always “ really good ”, as Dr Tonkin suggests .
It can be a type of colonisation of general practice , extracting data and using this to judge the worth of a community of doctors whose work is poorly understood .
I work with far too many Dr Janes — of all genders — who feel they are failing because they are unable to meet the quality metrics that are prescribed for them .
The side effect is a demoralised profession who are leaving , with substantial levels of moral harm .
Ultimately , this means less care for patients like Maria .
I cannot believe that this is the outcome the board is seeking .
I work with far too many Dr Janes who feel they are failing because they are unable to meet the quality metrics .