Quality assessment of primary health care in a military setting

Military Medicine,  Nov 2003  by Mandel, Dror,  Zimlichman, Eyal,  Ash, Nachman,  Mimouni, Francis B,  Et al

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Purpose: The aim of this study was to analyze the quality of primary care in Israeli Defense Forces primary care clinics and physicians (PCPs) and to test the hypotheses that: (1) the quality of primary care provided in battalions is higher than that provided by other primary care providers and (2) the evaluation of a specific PCP within the framework of the quality assessment program results in an improved score during a second evaluation. Methods: Teams of two physicians carried out the control process. Each primary care clinic is evaluated in a standardized manner by filling a prospectively established form. Five parameters are examined: (1) direct inspection of the PCP, (2) medical record audit, (3) high-risk patients' management evaluation, (4) evaluation of secondary health care characteristics, and (5) medical staff guidance evaluation. The various clinics and physicians evaluated were classified as: battalion clinics, division and brigade clinics, training center clinics, and home-front clinics. Results: Between the years 1999 and 2001, 149 primary care clinics and 250 PCPs were evaluated. Seventy-four PCPs (29.6%) were evaluated twice. Battalion clinics scored higher than the other clinics. PCPs evaluated twice had significantly better quality assessment results at the second encounter. Conclusions: Quality of primary health care is the highest in battalion troops clinics. We interpret the increase in quality assessment scores from one examination to the other as an index of improvement resulting from the feedback given to the providers.

Introduction

Quality assessment (QA) in primary care is a process of planned activities whose ultimate goal is to achieve a continuous improvement of medical care.1-4

The practice of primary health care within the Israeli Defense Forces (IDF) is similar in many aspects to that of civilian health systems, yet some characteristics are unique.5-9 (1) The military population is younger than the general population, thus likely to be healthier. (2) There is an abrupt change in lifestyle of young adults recruited in the army. However, there is a high availability of and accessibility to medical services with an average of seven to eight visits per soldier and per year (internal IDF unpublished data). (3) The medical system is challenged by the duty of fulfilling its obligations to both patients and commanders. (4) The primary care providers are younger and less experienced than the providers in group- and staff-model health maintenance organizations.

Each primary care physician (PCP) in the Israeli Army belongs to one of three groups: PCPs on active duty, physicians in the reserve army, and civilian PCPs employed by the army. The differences between these three groups are fundamental in respect to knowledge, skills, motivation, and identification with the system goals and values and thus may render quality of medical care uneven. These characteristics of the military medical system make it mandatory to develop a comprehensive, scientifically, and valid system able to identify variations in quality of care and to study the impact of corrective measures. The purposes of this study were to: (1) compare the quality of care provided by the different types of primary care clinics (PCCs) and PCPs in the IDF (we hypothesized that the quality of primary care provided in battalion settings is higher than that provided by other primary health care providers) and (2) analyze the preliminary impact of the QA program upon quality of primary care in a military setting (we hypothesized that the evaluation of a specific PCP within the framework of the QA program results in an improved score of the physician during a second evaluation).

Methods

Definitions

For the purpose of this analysis, the various PCCs and PCPs evaluated were classified in the following manner:

1. Battalion troop clinics are small, one-physician battalion clinics that serve deployed units either in the Israeli-Lebanon border, Golan Heights, or the Palestinian authority territories. The PCP is a medical officer on active duty. Apart from the PCP, military medics provide only elementary medical care and are for administrative functions as well. Physiotherapy, mental health services, and laboratory services are not available onsite, and only a restricted pharmacy capable of providing basic medications is available.

2. Brigade and division clinics are sedentary clinics located in camps with one or two PCPs, usually from the reserve army. In addition, medics provide elementary medical care and administrative procedures. Physiotherapy, mental health services, and laboratory services are not available onsite, and again, only a restricted pharmacy capable of providing basic medications is available.

3. Training centers clinics are larger clinics with two to three PCPs and a larger number of military medics. These clinics usually have mental health services but do not provide other above-mentioned services.

4. Home-front clinics are even larger PCCs that employ between 2 and 11 PCPs and are supported by medics and nurses that increase the number of available clinical staff. In addition, full laboratory, pharmacy, and radiology services are usually available onsite or nearby. Most centers also have physiotherapy and mental health services, whereas others include various specialist services in the same facility. Some also have inpatient facilities. In addition, most of these PCCs function also on evenings and weekends for urgent visits.