gms | German Medical Science

Since the late eighties, in Germany several health related laws established recommendations and rules with the explicit aim to stimulate quality assurance programms in primary care. Meanwhile, quality circles (QC) are generally considered to be an important tool for quality improvement in primary health care. This is especially the case in Hesse, where the Association of Sickness Fund Physicians (KV Hessen) and the VdAK/AEV Sick Fund support this approach for almost 10 years now.

To increase a more rational prescribing behavior. To develop and implement indicators for rational prescribing and risk reduction.

In Hesse, 612 general practitioners (GP) in 57 QC groups participated in the project from June 2002 to May 2003. Participants were provided with individual databased and practice comparison feedback reports which also contain information about appropriate therapeutic recommendations for common diseases such as hypertension, diabetes mellitus etc. Special training courses and supervisions were provided for quality circle moderators to facilitate discussions in the QCs. After the intervention, the extent of the influence on prescribing behaviour was quantified by prescribing indicators. The acceptance of the intervention is quantified by detailed protocols and questionnaires.

Both groups showed increasing prescription costs. However, using more generic drugs in the intervention group the increase of prescription costs (+2.2 %) was lower than the increase in the control group (+3.8 %). Some of the choosen indicators showed significant improvement in therapeutic quality in the intervention group: e.g. reduction of unreasonable drugs (p = 0.000) and drug combinations (p = 0.028), however, increased use of recommended medication such as certain antibiotic drugs (p = 0.000), antihyperglycemic agents (p = 0.005) and lipid lowering drugs (p = 0.035), respectively. The intervention was assessed as very helpful, relevant and essential (mean 2.0 on a six point scale) by the physicians.

Deriving quality criteria from routine prescribing data provided a foundation for improvement. The process resulted in a more rational prescribing: Increased generic prescribing, more use of therapeutically equivalent cheaper drug alternatives and avoiding drugs of limited clinical value. Changes occur slowly but voluntary participation, individual feed back reports and regular structurated meetings are suitable and well accepted tools to improve the GP´s prescribing practice.