GP Clinics a new paradigm in managing chronic disease

1
GP Clinics a new paradigm in managing chronic
disease

• Terry Rose
• www.opsun.com.au
• trose_at_opsun.com.au

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Who are we?

• Aberfoyle Park Medical Centre
• Southern Suburbs of Adelaide, S.A.

• 3500 patients (WPE Medicare stats)
• 5 doctors (3 FTE)

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GP clinics defined

• A clinic is a group of patients with a common
  diagnosis or problem
• E.g. cholesterol over 8, gout, eGFR under 60

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Overview

• 1 - Creating GP clinics - What surprises lurk
  within our medical records?
• 2 Using GP clinics - Can we use them to improve
  patient management?
• 3 Engaging patients in the management of their
  medical conditions
• 4 Comments on data extraction

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Creating GP clinics
Open source shareware - download from
www.opsun.com.au
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Notes on searching the database

• The examples are from MD2
• MD3 and Best Practice are essentially the same
  database
• For this presentation patient names are
  de-identified

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Search the Measures table
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GP clinic - last cholesterol gt8
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GP clinic - last cholesterol gt7
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Creating GP clinics
31 August 2007 Warning on gout link to heart
disease MEN with gout have a greatly elevated
risk of death from cardiovascular disease,
researchers have found, leading to calls for more
aggressive management of risk factors in these
patients.
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Search the Past History table
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GP clinic -gout
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Creating GP clinics
1 in 7 adults have some sign of CKD Symptoms of
CKD may not appear until kidney function is
severely and irreversibly impaired.
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GP clinic -CKD
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GP clinic -Renal Failure
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Try again
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Calculate eGFR from creatinine, age and sex
eGFR 186 (Serum Creatinine 88.4)-1.154
(Age)-0.203
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Search database for eGFR lt 60
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For eGFR lt 60 exclude old results
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Interpret data carefully

• July 2006
  150 patients with coded diabetes
• Dec 2006
  80 patients with coded diabetes
• Crude data extraction is fraught with substantial
  errors

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Using GP clinics
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Latest measures for the identified group
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Engaging patients

• By active feedback
• By targeted recalls

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Serial results for Mr R.E.
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Mr. R. E.These measures are used to help you
better manage your diabetes. Wednesday, 17
January 2007

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Return rates on mail-outs

• Diabetes clinic mail out inviting patients to
  attend a clinic 5 return rate
• Free 45 to 49 health checks (717) 10 return
  rate
• Latest targeted mail out over 50 return rate

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How do we do a mail-out?

• Choose our target group - e.g. last HbA1c over 6
  months ago, or HbA1c over 10
• Enclose latest results with targets and reasons
  for targets
• Enclose path request form - Hba1c, cholesterol,
  microalbumin etc
• A letter specifically asking patients to get the
  test done and see us a week after
• Personally signed by the doctor

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Choose according to latest results.This patient
has a HbA1c of 14.8, BP 180/80 and cholesterol of
5.1
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Create the target group
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Check last date doctor seen
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Last date doctor seen
 
 
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This is our mail-out
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Comment on data extraction

• Crude data extraction is fraught with
  systematic errors such as
• In July 2006 - 150 people with diabetes
• In Dec 2006 80 people with diabetes
• The denominator problem

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HbA1c June 2006 to May 2007
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IHD BP June 2006 to May 2007
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Some parameters - average changes
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Take home pointWe are making a difference
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Conclusions

• We can manage chronic diseases more pro-actively
  by using the GP clinics concept
• We can benefit from software that embraces the
  concept of managing clinics of patients
• We can provide serial results printouts to engage
  our patients in owning their management

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Conclusions

• Recalling targeted patients works
• For data extraction to be valid, patients will
  need to identify with a single Practice

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Thank you