Methods for quality development on the primary health care structure

Abstract: The overall aim of this thesis was to describe and analyse methods for quality development of the Swedish primary health care structure. Specific aims were as follows. To describe and test a medical-audit method of determining the optimum level of outpatient medical care. To describe and test the tracer-condition methodology for quality assessment of the medical care delivered by the primary health care. To describe and test a practice-visiting method to compare the total qualities of primary health care centres in order to facilitate quality improvement. To describe and test Donabedian's method (structure, process, outcome) of evaluating a health-promotion programme giving special attention to outcome. To use register data as a method to analyse important determinants of hospitalisation rates and whether the primary health care has any influence.Different methods for quality development, such as peer review, medical audit, practice-visiting and tracer-condition technique, were used in order to evaluate the quality of care at the primary health care centres and to identify the role of primary health care in the total health care system. Papers I-V were based on studies of everyday activities in ordinary health care centres and hospitals in three counties in southern Sweden during 1987-2000.The methods used were chosen and adapted for the purpose of the studies.It was agreed upon that about 75% of the outpatient visits to a doctor could be managed by a general practitioner (GP) (Paper I). There was no difference in quality when patients with insulin-treated diabetes mellitus visiting a GP were compared with those visiting a doctor at a hospital (Paper II). Practice-visiting proved to be a suitable method of comparing different primary health care centres with respect to medical quality (Paper III). A health promotion progrannne could be integrated into the everyday work at the health centres and was found to improve lifestyle habits and influence cardiovascular risk factors (Paper IV). The most important determinants of hospitalisation rates were age, the proportion of the population born abroad, the structure of the health care organisation, and the number of outpatient visits to hospital (Paper V).The different methods which have been described need to be adapted to Swedish primary health care. The methods described in this thesis (medical audit, the tracer-condition method, practice-visiting and Donabedian's method) were usable for the purposes described. Register studies yielded valuable information in analysing important factors for explaining hospitalisations.