1. Managing chronic disease:
what makes a general practice
effective?
FINDINGS FROM THE PRACTICE CAPACITY RESEARCH PROJECT*
moderate-to-severe asthma, hypertension and/or
W
hat are the best ways to set up a
general practice to manage chronic ischaemic heart disease. A large cross-sectional
disease effectively? Individual GPs’ Four aspects of practice capacity were studied: study investigating
medical skills, or systems to implement 1. Multi-disciplinary team working within the
clinical guidelines, on their own, do not ensure organisational systems
practice (involving GPs, nurses, practice
effective prevention and management of chronic managers, receptionists and allied health that support chronic
disease. New research highlights the importance professionals)
of practice capacity; the way a practice is 2. Practice-based clinical linkages with other
disease management
organised to provide quality care. providers and services was recently undertaken
Some key organisational factors for effective 3. Information management systems and the
extent to which the practice uses information in general practices
chronic disease care have been identified in
research conducted overseas, with the most technology to maintain these systems across Australia.
successful practice systems involving effectively (IM/IT maturity)
combinations of these:1,2 4. Business and financial management in the
practice.
Participants included
• Systems to ensure that patients’ clinical
information is readily accessible in a useful Clinical care was assessed according to:
247 GPs, 403 practice
format. This includes setting up and (a) adherence to evidence-based clinical staff and 7,505 patients
maintaining registers of patients with chronic guidelines, (b) patients’ health status, (c) patients’
disease conditions, and effective systems for perception of the quality of care, and (d) GPs’ with diabetes,
recalling patients. and practice staff members’ job satisfaction
• Systems to assist the doctor in making the
cardiovascular disease
(See study design on page 2).
right clinical decisions (in addition to the Continues on page 3 or moderate-to-severe
doctor’s clinical expertise)
• Providing patients with effective education BACKGROUND TO THIS RESEARCH asthma. The study
and support in managing their own medical design is described
conditions The prevalence of chronic disease is increasing,
• Establishing and maintaining good linkages due to population ageing, lifestyle factors and on page 2.
with community resources and services increased life expectancy.
• Effective teamwork between health providers. The detection and management of chronic
disease is best coordinated by general practice,
Important aspects of practice capacity include
yet its structure and services have been set up
organisational infrastructure (e.g. clinical and primarily to provide episodic care – without
patient services, staff management, financial systematic follow-up or an emphasis on the
systems, facilities), systems for improving the patient’s role in self-management.
quality of services (e.g. clinical audits, use of the
Australian Government initiatives such as the
‘Plan, Do, Study, Act’ model of change), and
Enhanced Primary Care (EPC) package, the
working relationships between everyone involved
Practice Incentive Payments (PIP), the Practice
in providing patient care, both within and beyond Nurse program, the Allied Health Item
the practice. Numbers and Chronic Disease Management
The Practice Capacity Research Study was (CDM) Item Numbers have been introduced to
designed to measure the degree to which selected help practices set up the systems necessary for
chronic disease care, supported by Australian
aspects of practice capacity are associated with
Divisions of General Practice. It is not known
the quality of care for patients with any of the
which organisational systems work best.
following chronic conditions: type 2 diabetes,
*The Cross Sectional Study of the Capacity of General Practices to Provide Quality Chronic Disease Care (2002–2005) was jointly
conducted by the University of New South Wales (UNSW) and the University of Adelaide, supported through a funding agreement
by Australian Department of Health & Ageing with the Centre for General Practice Integration Studies, UNSW.

2. METHODOLOGY
Study design
• Stage 1: Background information was gathered for the study from • Computerised clinical tools (e.g. decision support systems, discharge
Australian and overseas literature, consultations with key general practice summaries, guidelines)
stakeholders in Australia and focus groups with GPs, consumers, practice Method used: IM/IT Practice Profiling Interview#
staff and allied health professionals. The study design was developed in
consultation with state-based general practice organisations, divisions of 4. Business management systems
general practice and GPs. • Administrative processes (e.g. patient recall systems, Chronic Disease
• Stage 2: New research instruments were developed and validated, and Initiatives registration, accreditation by AGPAL)
the research methods were tested in a pilot study among 11 practices in • Staff management and development (e.g. staff appraisals, job description
New South Wales and South Australia. (The symbol # indicates methods reviews)
that were purpose-developed in Australia for this study.) • Market analysis (e.g. regular assessment of the practice as a business
• Stage 3: Participants were recruited through divisions of general practice. using the Strengths, Weaknesses, Opportunities and Threats [SWOT]
Each practice selected a random sample of up to 180 patients (up to 60 analysis method)
patients with each diagnosis: type 2 diabetes, ischaemic heart disease • Business development (e.g. risk management strategies, systems for track-
and/or hypertension, and moderate-to-severe asthma). Surveys and inter- ing and managing stock)
views were undertaken with 250 GPs and 400 practice staff, and 7,505 Method used: Business and Financial Maturity Practice Profiling Interview#
patients, representing a cross-section of general practice in New South
Wales, South Australia, Victoria, Tasmania, Queensland and the Measures of the quality of chronic disease care
Australian Capital Territory. Of the 97 participating practices, approxi- a. Quality of chronic disease care
mately 65% were metropolitan and the remainder regional or rural, 59% Adherence to established clinical procedures and measures of disease con-
had fewer than four GPs, 84% were Australian General Practice trol in:
Accreditation Limited (AGPAL)-accredited, and approximately 51% • type 2 diabetes and cardiovascular disease (e.g. assessment of blood
employed practice nurses.
pressure, lipids, HbA1c, microalbumin, eye examination, body mass
• Stage 4: The results were shared with participating practices and have index, foot checks)
been the basis of quality improvement activities carried out with the assis- • moderate-to-severe asthma (e.g. use of spirometry, checking the patient’s
tance of divisions of general practice. A workshop was held in December inhaler technique, patient education about trigger factors, assessment of
2004 to provide training for the participating Divisions of General severity and impact of asthma on everyday activity, written asthma action
Practice in the use of the practice capacity measurement tools. The plans)
National Forum on Practice Capacity was conducted in April 2005 to
• risk factor assessment (smoking, nutrition, alcohol use, physical activity)
launch the results of the research study. The results of this study are now
• care planning
being publicised throughout Australia.
• registers, monitoring and completion of cycle of care.
Measures of practice capacity Method used: General Practice Clinical Care Interview#
1. Teamwork within the practice
b. Patient-reported quality of care
• Team ‘climate’ within the practice (the culture of the practice, e.g. extent
Patients’ assessment of their general practice (e.g. accessibility, reception
to which staff share team objectives, support for new ideas, monitoring
services, continuity of care, GP’s communication skills, quality of personal
each other’s work quality)
care by GP, quality of care by practice nurse)
• Team structure, roles and functions
– Functions of practice nurses within chronic disease management (e.g. Method used: General Practice Assessment Survey4
recall systems, screening, patient education, delegated clinical tasks) c. Patient-reported health status
– Roles of administrative staff in supporting chronic disease care (e.g. Patients’ overall assessment of their health (e.g. general health, physical func-
processing documentation associated with CDM Medicare items, tion, mental health, pain status, emotional aspects)
administration of recall systems, practice management, meetings and
Method used: SF-12 health survey5
communication systems within practice)
Methods used: Team Climate Inventory (UK),3 Multidisciplinary Team d. GP and staff job satisfaction
Working Practice Profiling Interview# Practice members’ views of the job (e.g. work conditions, income, the
amount of responsibility given, freedom in the job, variety, work colleagues,
2. Practice-based clinical linkages with other providers and
opportunity to use abilities, recognition and hours of work)
services
• Referral links (e.g. established relationships with specialists for referral or Method used: Modified Job Satisfaction Scale (UK)6,7
advice)
• Collaboration with other providers in Shared Care arrangements and Analysis
Care Plans** (e.g. diabetes shared care, ischaemic heart disease shared
Practice capacity Outcomes
care)
• Involvement in community access and awareness initiatives 1. Teamwork within the practice a. Quality of chronic disease
2. Practice-based clinical care
Method used: Clinical Linkages Practice Profiling Interview# linkages with other providers b. Patient-reported quality of
and services care
3. Information management, including the use of information 3. Information management, c. Patient-reported health status
technology including the use of d. GP and staff job satisfaction
• The use of computers to store and access clinical records (e.g. diagnoses, information technology
pathology reports) 4. Business management
• The use of computers in patient education systems
• ‘Advanced’ information technologies, defined as the use of Public Key
Infrastructure systems (e.g. HIC online), paper-free office systems and Statistical analysis allowed investigators to measure how much variation in
electronic old files the quality of care (outcomes a to d) could be explained by the aspects of
• Computer-based administration (e.g. billing systems, financial records, practice capacity (1–4). It ensured that other factors like size of practice and
payroll) geographical area were taken into account.
**EPC items in use prior to July 2005, including Multidisciplinary Care Plans, were current at the time of this study.

3. RESULTS
A well-organised practice is good Table 1. Aspects of practice that influence quality of care
for patients’ health
Practice capacity Components Component most strongly
The quality of chronic disease care, as
area associated with quality of
measured against evidence-based clinical clinical care
guidelines, varied significantly between
practices but not between divisions of Team working • Clinical team roles Involvement of administrative
general practice. Overall, results for the • Administrative support roles and staff in systems that support
quality of clinical care indicated that there systems clinical care
is room for improvement, with average • Practice management structures
• Communication between team
scores highest for diabetes assessment and
members
lowest for asthma assessment (Figure 1).
Practices also differed in each of the four Information management/ • Computer-managed clinical records Computer use in clinical
areas of practice capacity. Scores reflected information technology • Computer-based administrative care, e.g. decision support,
relatively well-developed practice capacity processes guidelines, case finding,
in some areas, but suboptimal capacity in • Advanced IM/IT (See methodology discharge summaries
some areas, especially multidisciplinary on page 2)
• Computer use in clinical care
team work.
Within each of the four areas of practice Business and financial • Organisational and administrative Systems that support
capacity, the researchers then looked at systems processes business development and
• Staff management and skills planning
specific components and assessed their
development
effect on quality of chronic disease care.
• Market analysis
They identified those aspects of practice • Business development and planning
organisation most strongly associated with
high quality evidence-based clinical care Practice-based clinical Links with other providers for: Established systems for
(Table 1): linkages • shared care working with other
• IM/IT maturity: the use of computers to • access to community services organisations and care
• referral and advice providers
support clinical care, e.g. for decision
support, accessing discharge
summaries, case finding and clinical patient education materials, liaising with Practice size
guidelines other health providers for referrals, • Quality of care was found to be related
• Business management and financial maintaining service directories). to both the size of the practice and to
planning: evaluation of the financial practice capacity factors. Compared
However, patient care was best when
viability of introducing system changes, with larger practices (other factors being
practices also worked effectively with other
risk management strategies, stock equal), those with one to four GPs
outside organisations and care providers –
control, practice meetings, professional showed higher scores for quality of
to plan shared care, arrange referrals and
development for staff clinical care in type 2 diabetes,
obtain specialist advice, provide patient
cardiovascular disease and moderate-to-
• Team working: systems for monitoring education and promote community
severe asthma (Figure 2).
and training staff, involvement of awareness, and to facilitate access to
• However, larger practices scored higher
administrative staff in systems that support services. The quality of practices’ linkages
on measures of practice capacity, which
clinical care (e.g. maintaining was strongly related to the quality of
were positively related to quality of
register/recall systems, organising case chronic care they provided.
clinical care (other factors being equal).
conferences/health assessments, ordering
100 100
Score (% of total possible)
Score (% of total possible)
80
80
60
60
40
40
20
0 20
Diabetes Asthma Risk Factors Monitoring Care plans Teamwork Linkages IM/IT Bus/Fin
GP Clinical Care Interview domains Practice capacity
Figure 1. Quality of clinical care measured using a purpose-designed Figure 2. Practice capacity measured according to four aspects.
measure of best-practice care according to published guidelines (the
General Practice Clinical Care Interview)
Diabetes: quality of diabetes assessment; Asthma: quality of asthma assessment; Risk Teamwork: multi-disciplinary teamwork within the practice; Linkages: links with other
factors: assessment of chronic disease risk factors; Monitoring; extent to which the practice providers and services; IM/IT: IM/IT maturity; Bus/Fin: business and financial management
uses patient registers and monitors the cycle of chronic disease care; Care plans: Planning
for multidisciplinary chronic disease care.

4. RESULTS
This meant that greater practice also rated higher by patients on practices where nurses were responsible
capacity compensated for the negative quality of receptionist services. As for managing disease registers and
effect of greater practice size. expected, team climate was strongly recall systems.
• While patients rated the care provided associated with job satisfaction for
by practices very highly overall, smaller GPs and staff. Implications for Australian health
practices (fewer than four GPs) were care
Roles of practice nurses
seen as providing better access to These results indicate that the Australian
• After controlling for the effect of
medical care, better receptionist health system would benefit from an
practice size, there was no difference in
services, and better continuity of care. investment in supporting practices to
the quality of chronic disease
develop:
Other factors affecting patients’ management between practices with
• team roles, information systems and
evaluation practice nurses and those without.
business development processes to
• Practices with good clinical linkages • In practices in which nurses ran CDM
achieve evidence-based care
with other services for shared care, clinics, the quality of diabetes
• team climate within the practice
referral or advice and community assessment was significantly better than
• effective links with outside providers and
awareness were rated by patients as in practices where there were no nurse-
services, to ensure that patients with
offering greater access to care, after led CDM clinics.
chronic diseases can access the services
adjusting for practice size. • Assessment of diabetes, asthma and
they need over time.
• Patients expressed greater overall general risk factors for chronic disease,
satisfaction with practices that scored and overall care of patients with Achieving this will require coordination of
well for team climate among staff. diabetes, asthma or cardiovascular policy and programs at national, state and
Practices with good team climate were disease, was significantly better in local levels.
The practice capacity research study found:
• Practice organisation is important for good clinical care: the quality of chronic disease
care in general practice is related to the level of teamwork among staff, the use of
computers to enable effective medical record management and patient follow-up, and
attention to business planning.
• The quality of clinical linkages with other providers beyond the practice is also
important: practices’ scores on this measure correlated with overall quality of chronic
disease care and patients’ assessment of the care received.
• Smaller practices tend to achieve better clinical care (other factors being equal), but
larger practices can overcome this by better organisational systems.
• Practice nurses can make an effective contribution to chronic disease management.
References
1. Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Affairs 2001; 20 (6): 64-78.
2. Renders CM, Valk GD, Griffin S, Wagner EH, van Eijk JT, Assendelft WJJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and com-
munity settings. The Cochrane Database of Systematic Reviews 2000, Issue 4.
3. Anderson N, West M. Team Climate Inventory: user’s guide. Windsor: NFER Nelson, 1999. Available from: www.ase-solutions.co.uk
4. Ramsay J, Campbell J, Schroter S, Green J, Roland M. The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties. Family Practice
2000; 17: 372–379.
5. Ware JE, Kosinski M, Keller SD. SF-12®: How to score the SF-12® Physical and Mental Health Summary Scales. Lincoln, RI: Quality Metric Incorporated, 4th Ed, 2002.
6. Warr P, Cook J, Wall T. Scales for the measurement of some work attitudes and aspects of psychological well-being. Journal of Occupational Psychology 1979; 52: 129–148.
7. Ulmer B, Harris M. Australian GPs are satisfied with their job: even more so in rural areas. Family Practice 2002; 19: 300–303.
Centre for Primary Health Care and Equity, UNSW © 2006