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Table 2 Description of outcomes according to DHQP standards and data sources

From: Accreditation in general practice in Denmark: study protocol for a cluster-randomized controlled trial

Primary outcome DHQP standard ’aim’ Rationale Data source
Changes in number of prescribed drugs in patients older than 65 years in period 2.2. Prescriptions and prescription renewal: “Physicians in the practice have knowledge about the basic list for rational pharmacotherapy. The practice conducts, according to medical judgments, annual controls in patients with chronic disease, comprising assessment of prescriptions”. Inappropriate use of many concurrent drugs, especially in older people, imposes a substantial burden of adverse drug events, ill health, disability, hospitalization, and even death. National guidelines for general practice recommend critical reviews of the elderly patients’ medication, and secure medication in elderly patients relates to all four areas in DHQP, but most of all it relates to the patient security critical standards Medication Database (MD)
Secondary outcomes    
Polypharmacy in aged patients >65 years Polypharmacy Yes/No 2.2. Prescriptions and prescription renewal: “Physicians in the practice have knowledge about the basic list for rational pharmacotherapy. The practice conducts, according to medical judgements, annual controls in patients with chronic disease, comprising assessment of prescriptions”. National guidelines for general practice recommend critical reviews of the elderly patients’ medication (18)(18)(18)(15)(19)(18), and secure medication in elderly patients relates to all four areas in DHQP, but most of all it relates to the patient security critical standards. This variable is the dichotomized primary outcome defining polypharmacy as more than 5 concurrent prescribed medications. Medication Database (MD)
Patients >65 years taking NSAIDs without a concurrent prescription for proton pump inhibitor (PPI) Daily drug dose (DDD) of NSAID without PPI in period 2.2. Prescriptions and prescription renewal: “Physicians in the practice have knowledge about the basic list for rational pharmacotherapy. The practice conducts, according to medical judgements, annual controls in patients with chronic disease, comprising assessment of prescriptions”. Non-steroidal anti-inflammatory drugs (NSAIDs) can cause serious gastrointestinal complications, and it is estimated that more than 100 persons die from NSAID-induced gastrointestinal bleeding and perforation in Denmark annually. The risk is higher in the elderly. PPIs reduce the prevalence of bleeding gastric ulcers and reduce the risk of dyspepsia and uncomplicated gastric ulcers in NSAID treatment. Therefore, PPI treatment is recommended in combination with NSAIDs where these are requisite in patients older than 65 years of age. Medication Database (MD)
Sleeping medication Indicator: reduction in DDD sleeping medication/1000 patients DDD sleeping medicine in period 2.2. Prescriptions and prescription renewal: “Physicians in the practice have knowledge about the basic list for rational pharmacotherapy. The practice conducts, according to medical judgements, annual controls in patients with chronic disease, comprising assessment of prescriptions”. National guidelines from the National Board of Health recommend reduction in the prescription of sleeping medication. Medication Database (MD)
Preventive home visits Indicator: Changes in percentage of patients >75 years who have had a preventive home visit Preventive home visit Yes/No 1.2. Use of good clinical practice – vulnerable patient groups: “Patients are diagnosed, treated and provided support for self care and they are controlled, referred and rehabilitated in accordance with good clinical practice” The care of fragile elderly has a high priority and is addressed in this standard. Moreover, a specific fee for conducting preventive home visits to fragile elderly is part of the general practice remuneration system. The Danish National Health Services Register
Annual controls for chronic disease Indicator: changes in number of conducted annual controls for chronic disease/1000 patients Number of annual controls in period 1.2. Use of good clinical practice – chronic disease: “Patients are diagnosed, treated and provided support for self care and they are controlled, referred and rehabilitated in accordance with good clinical practice” Danish GPs coordinate most of chronic disease management and conduct annual controls. Remuneration for annual control is possible, only once a year, for certain chronic diseases: diabetes, psychiatric disease, cardiovascular disease (CVD), osteoporosis, chronic obstructive pulmonary disease (COPD), musculoskeletal disease, dementia and cancer. The Danish National Health Services Register
Spirometry in COPD/asthma Indicator: changes in number of conducted spirometry/1000 patients Spirometry Yes/No in period 1.2. Use of good clinical practice – chronic disease: “Patients are diagnosed, treated and provided support for self-care and they are controlled, referred and rehabilitated in accordance with good clinical practice” COPD and asthma patients should be monitored on an annual base with spirometry. GPs are remunerated with a certain fee for conducting spirometry. The Danish National Health Services Register
Number of reported adverse events (RAEs) Indicator: changes in number of RAEs RAE Yes/No in period per practice 1.3. Reported adverse events – the aim of the standard is to: “Reduce the risk of patient injuries following adverse events and to create learning and improvement on the background of reported adverse events”. Reporting of accidental events is addressed in standard 1.3. It is not only the aim to reduce the incidence of accidental events, but also to improve the management and learning potential of accidental events. Consequently, a simple count of RAEs may be equivocal. In order to avoid bias, we only analyse if at least one RAE has been reported from a practice in period. Danish Patient Safety Database (DPSD)
Patient satisfaction survey Changes in proportion of practices with a patient satisfaction survey in period 1.4. Patient evaluations – the aim of the standard is to: “Generate learning and improve the clinic’s services on the basis of patient feedback”. Patient-experienced quality will be surveyed using data from DANPEP (Danish Patients Evaluate Practice) (23, 24). DANPEP is a nationwide, continuous assessment of patient contentment in general practice. We only evaluate if a patient satisfaction survey is conducted in period. DANPEP database (Danish Patients Evaluate Practice).
Mortality Indicator: changes in mortality rates (deaths/1000 inhabitants) Number of deaths in 2-month period after index date   Mortality is the ultimate measure for effects of all applied interventions in health sciences. Any changes in mortality rates in relation to accreditation are of interest and should be a focus for analysis. Data on mortality rates can be obtained from (SD). Danish Register of Causes of Death
  1. SD Statistics Denmark (StatDen)