Guest Commentary: Physician Profiling in Emilia-Romagna Italy: A Tool for Quality Improvement

7
Dec

Vittorio Maio, PharmD, MS, MSPH,
Associate Professor
and Valerie Pracilio, MPH, Project Manager
for Quality Improvemement
Jefferson School of Population Health

This is the second in a series of blog postings summarizing issues, methods and results from current research in the Center for Value in Healthcare. We will be presenting a JSPH Forum entitled “Translating Research into Policy and Practice” on January 11th, 2012 with more details of the Center’s work.

Assessment is part of our daily lives. In school, we apply for admittance; in employment, we are screened before being hired, and once we’re “in,” we are regularly evaluated to ensure that we are performing at a level deemed appropriate. In the Italian Healthcare System a similar approach is being used to engage primary care physicians in quality. Performance data presented to physician teams is the first step in a profiling process. Not only does this help raise their awareness about the level of care they are providing, but it also engages them in discussions with their peers about what they can do to improve.

By definition, physician profiling is an analytic tool used to compare physician practice patterns across quality of care dimensions (American Academy of Family Physicians). The benefit is that it raises provider awareness of quality through feedback to stimulate improvement.

In Italy, primary care, provided by general practitioners (GPs), is the foundation of the Italian National Health Service, which maintains universal coverage to all citizens either free or at minimal charge at the point of service. Traditionally, GPs have worked in solo practices. However, in the last ten years, in an effort to increase coordination of care, the Italian National Health Service has introduced substantial reforms seeking to encourage collaborative arrangements among GPs. In order to build on earlier national reform, the Emilia-Romagna region (a large region located in northern Italy with a population of about 4.6 million inhabitants) passed a law in 2004 that required GPs to join a Primary Care Team (PCT).

In a PCT, GPs, many of whom are in solo practice, act in full autonomy, but are part of clinical networks designed to provide patients with integrated delivery of healthcare. Specifically, in a PCT, GPs are mandated to collaborate and share information, and by means of clinical governance, to engage in improving the quality of healthcare services provided to patients.

To this end, using the regional healthcare administrative database, the Emilia-Romagna region and Thomas Jefferson University began a collaboration to provide PCTs with information about the quality of services delivered to their patients via PCT profiles. GPs discuss the PCT profile data they are presented with their colleagues in their PCT and initiate PDSA cycles of improvement to make changes to their practice accordingly. Through a collective agreement with the region, GPs receive incentives to participate in the activity.

In the U.S., where the mission is not unified as it is in Italy, the focus has been on paying for performance rather than participation. There is something to be said for the focus on participation that has been demonstrated in Italy to invite physicians into the conversation about quality and actively engage in improvement. In the current U.S. healthcare environment, the stakes are being raised and soon the incentives for improving will turn into disincentives for not meeting standards.

Should we be focused on engaging physicians in quality through a non-punitive approach such as the one our colleagues in Italy are using, or continue to expect physicians will meet quality goals if incentivized? We’re interested in your thoughts.

Comments

  • Danielle Casher
    December 8, 2011

    What are the measures being used to evaluate clinician quality? Are they aspects of care that the physicians control (such as administration of influenza vaccine to all of those eligible at the time of the visit) or are they measures similar to those being used by third party insurers in the US that are partly contingent on patient action (such as adolescents coming yearly for well checks)?
    If providers are being measured for aspects of care that are beyond their direct control, are there public health initiatives to address these?

  • vittorio maio
    December 12, 2011

    For Danielle Casher:
    The choice of the indicators was dictated by he available administrative healthcare data, including hospital care, outpatient pharmacy data, and specialty care. These indicators include information on several clinical areas related to the activities provided by the GPs; however, these activities require patient’s action. Quality indicators, their specifications, and related literature are available in the Emilia-Romagna region website at http://www.regione.emilia-romagna.it/prim/
    In my opinion, these measures better suit for a “medicine of initiative:” they force the doctors to search in their medical records for patients who did not perform certain required care and begin pro-active initiatives to change patients’ behavior.

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