Improving Quality of Care through Primary Care Research
Machiko Inoue, MD, MPH, PhD
Associate Editor, JGFM
This issue of Journal of General and Family Medicine covers a variety of topics in original articles, reviews, case reports, and more, from which readers can learn and apply the knowledge in clinical care. Since the research topics in general and family medicine cover a vastfield, residents, primary care physicians, and other health professionals who are starting out in research might consider it hard tofind a suitable topic to pursue at first. Infinite opportunities abound, and Japan’s primary care medicine lacks evidence obtained from practice settings, and thus we are unaware of how wide an evidence-practice gap may exist. To improve the quality of primary care in Japan, we need vigorous research conducted within primary care practices. In this editorial, I suggest some tips to help early-stage researchers in primary care to generate research questions. The first is to pay attention to the quality of care at your own practice or in other settings, and discern any gap between ideal care based on estab-lished evidence or suggested by guidelines as “stand-ard,” and the care actually provided at the practice. Any gap in care that should be narrowed or eliminated as far as possible implies measures toward a solution should be sought. Practice-based research questions arise from those gaps, along with any uncertainty physicians and staff are experiencing. Such gaps have the potential to offer learning opportunities as well as research questions. Moreover, translational or implementation research for an intervention, whether pharmaceutical,
behavioral, or socioecological, in practice settings or in a population, would be a pursuable area for primary care researchers. Thinking about the topics and questions that primary care researchers could pursue would yield a niche in thefield.
The second tip is to keep the principles of primary care in mind and revisit them when you are unsure what could be done to recognize the care gap. These principles include accessible, comprehensive, coordi-nated, continuous, and patient-centered, as well as family- and community-oriented care. In Japan, how-ever, ways to define, assess, and improve the quality of primary care have not yet been established. This is partly due to a long history where general medicine/ family medicine has not been recognized as a specialty. The value and role of primary care are still ambiguous for patients, healthcare providers, and the public, although it has significant importance in the healthcare system. Therefore, it is inevitable for primary care academics to define the standard for primary care according to its principles. By doing so, the existence of“gaps in care” could be assessed and efforts toward quality improvement (QI) could take place.
Looking at the recent primary care reform in the United States would provide Japanese researchers some insights to think about a framework to reinforce QI in primary care. Fifteen years ago, the Institute of Medicine (IOM) in the United States issued a keystone report, “Crossing the quality chasm: A new health
Corresponding author: Machiko Inoue, MD, MPH, PhD Beth Israel Deaconess Medical Center, Harvard Medical School © 2016 Japan Primary Care Association
Journal of General and Family Medicine 2016, vol. 17, no. 4, p. 267–269.
Editorials
system for the 21st century”.1 Since then, pursuit of
higher quality and better safety in health care has been recognized as a compelling issue, more than ever, and has been discussed along with the sustainability of health. In the report, the IOM defined quality of care as following six aims: care should be safe, effective, patient-centered, timely, efficient, and equitable. Im-plementation of various polices, including the Afford-able Care Act, in terms of primary care, and redesign of the delivery model by putting into effect the Patient-Centered Medical Home (PCMH), have brought a major paradigm shift for primary care practices, requiring them to have a systematic focus on QI and safety.2PCMH attempts to shift the medical paradigm from the care of an individual patient by physicians to care by a team of providers with coordination and communication for various populations. A number of tools and external supports for implementing the PCMH were developed and became available for primary care practices’ use. External supports for QI include data feedback and benchmarking, practice facilitation, expert consultation, and learning collabo-ratives.2 Recognition by the National Committee on Quality Assurance (NCQA) has further pushed forward the transformative process taking place at practices, which defines the criteria for PCMH practices from level 1 to 3, with incentives to actively improve the quality of care and to meet the criteria to earn the recognition of level 3. The NCQA PCMH 2014 recognition is based on the following six standards: patient-centered access, team-based care, population health management, care management and support, care coordination and care transition, and performance measurement and quality improvement. Recent studies show that the implementation of the PCMH model has had some impact on the quality of primary care; it was associated with improved cancer screening rates,3
increased accessibility and patient-physician commu-nication,4 and modest improvement in healthcare
utilization.5 These efforts and achievements in U.S. primary care practices provide Japanese primary care researchers some implications for practically imple-menting QI within a healthcare system.
Third, assessing the impact on patient-centered out-comes would be an essential approach in primary care
research. The PCMH practices in the United States employ periodic surveys of their patients’ experiences with their practice, as an indicator of patient-centered-ness. The survey results are utilized for evaluating and further improving the quality of care. In addition, involving patients and their families as advisors in QI activities at PCMH practices is recommended. Some Japanese primary care practices are collecting patient satisfaction data, but whether patients are experiencing the care that a practice should provide may not be assessed thoroughly enough to change and improve the quality of care. As a starting point for quality assessment from the perspective of patient-centered-ness, conducting a patient survey is a viable option for primary care researchers. The PCMH initiative uses “the Consumer Assessment of Healthcare Providers and Systems (CAHPS)” surveys to assess patient experiences and create a database.6 To assess patient
experiences in primary care practices or for a population in Japan, a Japanese version of the Primary Care Assessment Tool (JPCAT), a 29-item survey that coversfive primary care principles, was developed and made available for use.7 Patient-centeredness is not only an important core concept in primary care, but it should be practiced as part of a system-based approach, as a measurable entity, in every practice. Afirst step to assessing the quality of care provided in a practice could be made from this aspect.
With the three suggestions mentioned above, I would encourage investigators to think outside the box, learning from the primary care movement in various countries, and pursue research to advance the quality of primary care in Japan.
References
1 Crossing the Quality Chasm: A New Health System for the 21st Century. In. Washington (DC): Institute of Medicine (US) Committee on Quality of Health Care in America. 2001.
2 Quality Improvement in Primary Care - External supports for practices [http://www.ahrq.gov/research/ findings/factsheets/quality/qipc/index.html].
3 Markovitz AR, Alexander JA, Lantz PM, Paustian ML: Patient-centered medical home implementation and use of preventive services: the role of practice Journal of General and Family Medicine 2016, vol. 17, no. 4
socioeconomic context. JAMA Intern Med. 2015; 175: 598–606.
4 Shi L, Lock DC, Lee DC, et al: Patient-centered medical home capability and clinical performance in HRSA-supported health centers. Med Care. 2015; 53: 389–395.
5 Kern LM, Edwards A, Kaushal R: The patient-centered medical home and associations with health
care quality and utilization: a 5-year cohort study. Ann Intern Med. 2016; 164: 395–405.
6 CAHPS Surveys and Tools to Advance Patient-Centered Care [http://www.ahrq.gov/cahps/index. html].
7 Aoki T, Inoue M, Nakayama T: Development and validation of the Japanese version of Primary Care Assessment Tool. Fam Pract. 2016; 33: 112–117. Improving Quality of Care through Primary Care Research
