Notat om APO-netværket
Audit Projekt Odense (APO) udfører kvalitetsudviklings- og forskningsprojekter i sundhedsvæsenet både i Danmark og internationalt. Vi anvender APO-metoden, som består af deltagerudført aktivitetsregistrering, individuelt og kollektivt feedback, ekspertvurdering og fagfællediskussion. APO-metoden er blevet forfinet gennem hundredvis af projekter over mere end 30 år (LINK til History of APO). Den er evidensbaseret og internationalt anerkendt. APO er en del af Forskningsenheden for Almen Praksis i Odense og hovedparten af vore projekter foregår i det primære sundhedsvæsen.
Audit Projekt Odense (APO) performs quality improvement- and research projects in Danish and international healthcare settings. We apply the APO-methodology, which includes self-registration of activities, individual and collective feed-back, expert involvement, and peer-discussion. We have applied and refined the method in hundreds of projects during more than 30 years. (LINK to History of APO). The APO method has proven scientifically valid and feasible in many healthcare settings worldwide. APO is a part of the Research Unit of General Practice in Odense and most of our projects involve primary care.
The APO method
The APO method is an evidence-based internationally accepted approach for quality development and collection of research data in health care settings worldwide(1-4). The projects are usually initiated bottom-up and must primarily aim to improve the performance of the participating healthcare professionals. Participation should be voluntary and participant representatives should be involved in planning the projects. In traditional medical audits a panel of external specialists retrospectively assess the quality of care which is primarily reported to chief executives and third parties. In APO audits the participating healthcare professionals prospectively register their own activities and the resulting report is targeted at themselves and conveyed at a meeting with peer discussion and expert lectures.
The APO method has been applied on many topics including infections(3, 5-9), cardiovascular diseases (10), elderly patients (11), pain, defensive medicine (12), tympanometry (8), point-of-care ultrasound (13), teledermoscopy (14), low back pain, cancer diagnostics, gastric-(15), and psychiatrics conditions (16). Suitable topics for the APO method must occur frequently, preferably more than twenty times during the registration period, which can last down to only one day and preferably not more than twenty working days. If the topic of interest occurs seldomly such as diagnosing a new patient with cancer in primary care, the audit may be held retrospectively as a journal audit based on identification of cases in the electronic medical records (17).
Participation of minimally 30 healthcare professionals is usually enough to demonstrate the participants’ collective quality of care in sufficient detail, secure the participants’ anonymity in the report, and provide them with sufficient bench-marking opportunities. If regarding the audited topic the healthcare professionals work close together in groups, such as GPs and staff in a clinic, it may be reasonable to organize participation in groups rather than individual.
Registration is made on the APO chart following certain rules. (LINK til The APO registration chart)
The APO registration chart
The A4 paper APO chart is developed to facilitate registration of multiple episodes of a frequently occurring health care activity in a simple and fast way, obtaining sufficient data to measure the quality of care, and provide the recording participant with an overview over the topic of interest and the participant’s own recordings.
The APO chart is filled in by the health care professional in charge of the activity of interest. The questionnaire items are lined up in columns. Beneath, each activity episode e.g., a consultation, is recorded by filling in a line in the chart. Generally, the method only allows questions that can be answered by ticking, but few boxes may be filled in with numbers. Free text answers are never allowed.
A maximum of 45 item columns are allowed. The columns are divided into maximally ten main questions each with maximally ten answer option columns. The main questions should follow the expected order of actions during the activity of interest. For example, in the general practice setting: consultation type?, symptoms?, examinations?, diagnosis?, treatment?, and assessment?. The answer columns to each main question need to be exhaustive (include all possibilities) and exclusive (no overlapping of answers) meaning that at least one tick is needed for each main question.
In general, the registration should be made quickly affection the conduct of the activity as little as possible. This allows the healthcare professional no time for obtaining informed consent from involved patients. Therefore, the patients must be unidentifiable in the records. This is usually possible given the high frequency of the recorded activities. (Insert figure APO chart from HAPPY Audit).
History of APO
In the 1970s, a simple chart was developed at the Birmingham Research Unit for General Practice, suitable for prospective self-registration of activities in general practice (6). In England many different practice activities were registered by means of this chart during the seventies and eighties, but when the registrations were repeated one year later, hardly any improvement in the quality of care had taken place.In the late eighties, four Danish general practitioners (GPs) from the Department of General Practice at Odense University visited the Birmingham department and were taught the basic rules for conducting these practice activity analyses (PAA). Having obtained this knowledge, the GPs returned to Odense and in 1989 the APO unit was established. Later, in 1993, APO became part of the Research Unit for General Practice at the University of Southern Denmark (7).
APO further developed the registration chart (Link til The APO registration chart)and added to the method a thorough feed-back course activity which was offered to the participants between the two rounds of registration and soon proved to be a vital key to success. The first application of the APO method on acute respiratory tract infections (RTIs) in 1992-1993 resulted in significant improvement of the included quality indicators, thereby increasing the interest in the method (8). Since then, APO has used the method in hundreds of projects targeting multiple topics, settings, and countries.
APO har siden 1993 forestået et nordisk netværk med deltagelse af auditprojekter i Sverige, Norge, Island og Finland. Det nordiske netværk har sidst været samlet på de almenmedicinske kongresser i Tromsø 2011 og i Tampere september 2013. Aktiviteten er i øjeblikket sparsom.
Leder af APO
Jesper Lykkegaard – praktiserende læge og leder af APO fra 1. januar 2018. Medlem af APOs koordinationsgrupper siden 2014. Seniorforsker på Forskningsenheden for Almen Praksis i Odense, har skrevet Ph.d. om KOL relateret emne.
Anders Munck har været praktiserende læge siden 1978 og var med til at danne APO i 1989. Har ledet projektet siden 1991, og er fra 1. januar 2018 tilknyttet projektet som seniorkonsulent.
Susanne Døssing Berntsen
Susanne Berntsen sekretariatsleder, edb-assistent. Varetager ledelsen af APOs sekretariat, har ansvaret for logistikken i forbindelse med APO projekter, og foretager databearbejdning, analyse og rapportudarbejdelse. Har været tilknyttet APO siden starten 1989.
Merethe Kirstine Andersen
praktiserende læge, ph.d. , seniorforsker. Deltager i mange af APOs projekter med fokus på mulighederne for videnskabelig afrapportering.