HARC eBulletin - September 2009
Hospital
September 2009
The Australian healthcare reform agenda contains a vision for evidence being embedded into both the design and evaluation of changes to the health system. In this edition, we highlight the latest studies from the UK where they have produced a steady stream of high quality evaluations of the Blair government's NHS reforms. These latest studies capitalise on using routinely collected hospital data to evaluate national changes to hospital operations, a method that has been used in the US by the Dartmouth Atlas Project over the past 20 years to monitor variation in US healthcare. We are delighted that Professor Elliott Fisher from Dartmouth, whose internationally acclaimed research has been instrumental in shaping the US healthcare reform agenda, will be speaking at our forthcoming November HARC forum and I hope you can join us (details below).
Other topics we cover in this edition are: palliative care for advanced cancer patients; savings by reducing hospital acquired infection rates; health literacy in Australia; and implementing evidence based care.
Enjoy clicking through our round up of the latest research and big ideas to emerge over the past quarter.
Mary Haines
Health Services Research Director
To download the print version Click Here
Review Round-Up
- Point of care computer reminders bring modest improvements in processes of care
- Existing health care efficiency measures reflect cost not quality
- Better care in not-for-profit compared with for-profit nursing homes
Research Round-Up
- A new policy for payment by results reduces cost not quality in English hospitals
- NHS reforms have reduced waiting times and inequality of access for elective surgery
- A way to improve quality of life for advanced cancer patients
- Infection control in Australian hospitals can reduce bed block and save money
- Implementing evidence based care in Australian Emergency Departments - appropriate use of Ottawa ankle rules
Report Round-Up
What Are People Talking About?
- What is Medicare Select?
- New NHS hospital comparison website
- The case for health reform
- Improving quality and safety in hospitals - a practical guide
Forthcoming Events
Review Round-Up
Point of care computer reminders bring modest improvements in processes of care
Clinical information systems provide an opportunity to improve care by delivering decision support to clinicians at the point of care. However, previous reviews of computer reminder and decision support systems have reported mixed results.
The aim of this review from the Cochrane Collaboration was to evaluate whether on-screen computer reminders delivered to physicians at the point of care effectively improve processes and outcomes of care and if there are any identifiable elements which influence the effectiveness of these reminders. Twenty eight studies reporting 32 comparisons from randomised or quasi-randomised trials met the inclusion criteria.
Point of care computer reminders generally resulted in small to modest improvements in process adherence with median improvements of 3.3% for medication ordering and 3.8% for both vaccination and test ordering. Interventions that targeted inpatient settings tended towards larger improvements in processes of care than those in outpatient settings. Larger effects were found with reminders that required users to enter a response into the computer about patient care. However, the authors concluded that 'the current literature does not suggest which features of the reminder systems, the systems with which they are delivered or which target problems might consistently predict larger improvements' .
Shojania KG, Jennings A, Mayhew A et al. The effects of on-screen point of care computer reminders on processes and outcomes of care. The Cochrane Library 2009; Issue 3. Follow the link to the full review [cited 2009 September 23]
Existing health care efficiency measures reflect cost not quality
Health service managers, clinicians and policy makers all agree that ongoing monitoring of the health system is important to drive improvements. What remains unknown is how we can conceptualise and measure the efficiency of health care systems so that they can be evaluated and improved.
The aim of this systematic review, published in Health Services Research , was to characterise and evaluate the adequacy of 265 existing health care efficiency measures identified in the peer-review literature and 8 measures in the gray literature.
Measures tended to use health services as outputs, reflecting cost of care, average length of stay or focusing on physician efficiency. Less than two percent of measures included health outcomes as outputs and only one explicitly incorporated the quality of care. Evidence of the measures' scientific soundness was mostly lacking leading the authors to conclude that, unlike most quality measures, efficiency measures '… have been subjected to few rigorous evaluations of their performance characteristics including reliability, validity and sensitivity to methods used' and that 'almost all of the purported efficiency measures reviewed would be classified as "cost of care" measures… not true "efficiency measures"' .
Hussey P S, de Vries H, Romley J et al. A Systematic Review of Health Care Efficiency Measures. HSR 2009; 44 (3): 784 - 805. Please click here for the full article [cited 2009 September 23]
Better care in not-for-profit compared with for-profit nursing homes
As the demand for nursing home care increases there remains widespread concern about the quality of care in nursing homes among researchers, policy makers and the press.
The aim of this systematic review and meta-analysis of 82 studies conducted between 1965 and 2003, published in the British Medical Journal , was to compare the quality of care in for-profit versus not-for-profit nursing homes. Results were pooled for the four most common measures of quality of care, namely: number of staff per resident or level of staff training; the use of physical restraints; incidence of pressure ulcers; and regulatory deficiencies.
Meta-analyses suggested that not-for-profit facilities, whether publicly or privately owned, delivered higher quality care than for-profit facilities. 40 studies reported statistically significant differences in the number or quality of staff and the prevalence of pressure ulcers. There was also less use of physical restraints and fewer deficiencies in governmental regulatory assessments in not-for-profit nursing homes but these findings were not statistically significant. Only three studies favoured for-profit facilities whilst the remainder reported mixed results. The authors suggest that "if quality or appropriateness of care varies significantly by ownership, this should influence government policies related to regulatory assessments and the use of public funds for nursing homes".
Commodore V R, Devereaux P J, Zhou Q et al. Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis. BMJ 2009; 339: b2732. The full review can be read here [cited 2009 September 23]
Research Round-Up
A new policy for payment by results reduces cost not quality in English hospitals
In 2002, the English NHS implemented payment by results (a fixed tariff case mix based payment system) in hospitals to increase efficiency, volume of activity and quality of care. At the time when the changes were implemented, health care providers were concerned that financial reforms may compromise quality of care.
This study, published in the British Medical Journal , focuses on evaluating the first years of the policy implementation and seeks to answer whether the policy achieved its aim. The study was designed as a quasi-experiment, using naturally occurring control groups, to compare measures extracted from routinely collected hospital data of: volume; cost; and quality of care between 2003/4 and 2005/6 in acute hospitals in England by comparing results with those from Scottish hospitals.
The results of a difference-in-difference analysis for proxy measures of unit cost (length of stay and proportion of day case admissions) suggest unit costs fell more quickly with the implementation of payment by results as did length of stay, with an average saving of eight inpatient days per 100 inpatient admissions. In addition, the proportion of elective care provided as day cases increased more quickly where payment by results was implemented. There was little evidence of an association between the introduction of payment by results and changes in quality of care indicators (i.e. changes in in-hospital mortality, 30 day postsurgical mortality, and emergency readmission after treatment for hip fracture). The authors tentatively conclude that "reductions in cost have been attained through increases in efficiency rather than through reductions in quality".
Farrar S, Deokhee Y, Sutton M et al. Has payment by results affected the way that English Hospitals provide care? Difference-in-differences analysis. BMJ 2009; 339: b3047. You can read more of this study here [cited 2009 September 23]
NHS reforms have reduced waiting times and inequality of access for elective surgery
Waiting times in English hospitals dropped considerably between 1997 and 2007 in response to several government initiatives but little is known about whether this drop has been equitably distributed between socioeconomic groups. At the outset of the NHS reforms, some feared that reduction in waiting times would differentially benefit patients in hospitals in more affluent areas compared with those in lower socio-economic areas. So did waiting time reduction come at the expense of equity?
Published in the British Medical Journal, this retrospective study of population-wide patient level data examined three common, high volume elective procedures with chronically long waiting times: knee replacement (427,227 patients); hip replacement (406,253 patients); and cataract repair (2,568,318 patients) in the English NHS from 1997 to 2007. The main outcome measures were the number of days waited from referral for surgery to surgery itself and socioeconomic status as measured by the Carstairs index of deprivation. Both mean and median waiting times rose initially then fell steadily over time. In 1997 there was a significant positive association between waiting times and deprivation (i.e. the greater the degree of deprivation, the longer the waiting time) but variation in waiting time across the population became more uniform by deprivation by 2007. The relationship was even reversed for cataract repair and knee replacement with patients from the most deprived fifth waiting less time than those in the most advantaged fifth leading the authors to conclude that NHS reforms "at a minimum, did not harm equity and that contrary to critics' fears, by 2007 patients' deprivation had little impact on their waiting times".
Cooper Z, McGuire A, Jones S et al. Equity, waiting times, and NHS reforms: retrospective study. BMJ 2009; 339; b3264. The can full article can be found here [cited 2009 September 23]
A way to improve quality of life for advanced cancer patients
Providing palliative care in conjunction with oncology treatment has been proposed as a means to improve quality of life for patients with advanced cancer but few studies have examined the effectiveness of palliative care interventions.
This randomised control trial, conducted between November 2003 and May 2008 in American cancer care settings, tested the effect of a nursing-led multicomponent, psychoeducational intervention (Project ENABLE) on quality of life, symptom intensity, mood and resource use. A total of 322 patients with advanced cancer were assigned to either the intervention (N=161) or usual care groups (N=161). The intervention group participated in 4 initial structured educational and problem-solving sessions then telephone follow-up sessions at least once per month. The results of the study, published in the Journal of the American Medical Association, demonstrated a significant positive effect on quality of life and depressed mood for the intervention group. Symptom intensity did not differ significantly between the two groups nor did the number of days in hospital or intensive care unit or emergency department visits. Post hoc analyses found no significant differences in survival rates between the two groups. The authors suggest that "While our study did not show that early intervention for patients with advanced cancer by a nurse-led program improved symptoms or reduced use of some resources, the study did show that it provides some patients with advanced cancer a higher quality of life and mood".
Bakitas M, Doyle Lyons K, Hegel M et al. Effects of a Palliative Care Intervention on Clinical Outcomes in Patients with Advanced Cancer. JAMA; 302 (7): 741. Please click here to read the full article [cited 2009 September 23]
Infection control in Australian hospitals can reduce bed block and save money
In Australia, acute care hospitals are focused on improving the cost-effectiveness of health services. Interventions that reduce the risk of adverse events, such as hospital acquired infections, that increase length of stay and cost to the system are one strategy to improve cost-effectiveness. So what would be the benefit for the health system if we could reduce hospital acquired infection?
This study, published in Healthcare Infection, aimed to predict the economic consequences of healthcare-acquired infections in Australian acute care hospitals by developing a quantitative algorithm derived from all admissions to general medical and general surgical specialties from every acute care hospital in the country. The main outcome measures were the number of healthcare-acquired infections and the number of bed days lost annually. The results are compelling with more than 175,000 estimated cases of healthcare-acquired infection resulting in over 850,000 extra bed days needed to treat symptoms per annum. The algorithm suggests that a 1% reduction in infection rates would release approximately 150,000 bed days for alternative uses, allowing around 38500 new admissions annually. The authors infer "cost-effectiveness of hospital services might be improved by allocating more resources to infection control, releasing beds and allowing new admissions".
Graves N, Halton K, Paterson D & Whitby M. Economic rationale for infection control in Australian hospitals. Healthcare Infection 2009; 14: 81-88. Click here to read more [cited 2009 September 23]
Implementing evidence based care in Australian Emergency Departments - appropriate use of Ottawa ankle rules
Virtually all patients with blunt ankle trauma are referred for radiography but fractures are only present in around 15% of cases. The Ottawa ankle rules are a clinical decision tool that aids the efficient use of radiography in acute ankle injuries but their application varies considerably resulting in unnecessary cost and exposure to radiation.
Published in the British Medical Journal , this before and after study based in the emergency departments of a tertiary teaching hospital and a community hospital in Australia examined the effects of a multifaceted change strategy on documentation of the Ottawa ankle rules, the proportion of patients referred for radiography and the proportion of radiographs showing a fracture. The strategies for change included: education; a problem specific radiation request form; reminders; audit and feedback; and using radiographers as gatekeepers.
For the sample of 1561 patients, documentation of the Ottawa ankle rules improved significantly rising from 57.5% to 94.7% in the tertiary hospital and from 51.6% to 80.8% at the community hospital. There was also a significant reduction in the number of patients referred for radiography, while the proportion of radiographs showing a fracture significantly increased. The missed fracture rate rose slightly compared with baseline but this change was not significant. According to the authors the request form was particularly well adopted with hospital staff acknowledging "that it served not only as a memory aid but also described the appropriate population with which the Ottawa ankles rules should be used".
Bessen T, Clark R, Shakib S & Hughes G. A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments. BMJ 2009; 339: b3056. Follow the link to the full study [cited 2009 September 23]
Report Round-Up
Health Literacy among Australians - only 41% of adults have adequate or better health literacy skills
This report from the Australian Bureau of Statistics covers the findings from the 2006 Adult Literacy and Life Skills Survey (ALLS) which measured the literacy of adults in several key areas including health literacy which is defined as 'the knowledge and skills needed to understand and use information relating to health issues such as drugs and alcohol, disease prevention and treatment, safety and accident prevention, first aid and staying healthy'. The report compares the overall level of health literacy, which assesses 41% of adults as having adequate or better health literacy skills, with different sociodemographic groups revealing that levels of health literacy were highest in: the 20-49 year age group; people with excellent or very good self-assessed health; and those with higher educational levels. Health literacy was also affected by income with 63% of people in the high income group having adequate or better levels in comparison with 26% in the low income group. When results were adjusted to cover the same age sample, the proportion of adults achieving adequate or better health literacy scores in Australia (43%) was similar to that found in a Canadian survey (45%).
The full report can be accessed by clicking the link. [cited 2009 September 23]
The impact of financial incentives on quality of care - jury still out
This report from the Health Foundation, updated and republished in July 2009, reviews the published international literature to determine how financial incentives affect the quality of care delivered by healthcare organisations and individuals. It provides guidance to policy and decision makers who aim to improve quality of care through payment reforms by addressing two key issues: 1) the effectiveness of financial incentives directed at improving quality; and 2) the secondary effects of financial incentives intended to restrain costs and utilisation on quality of care. The authors observe that "The literature on the influence of financial incentives for healthcare providers on quality of care is underdeveloped, but that situation seems to be changing at a relatively rapid pace".
Click here to download publication.[cited 2009 September 23]
New South Wales Population Health Survey available now
The 2008 Report on adult health from NSW Health documents the health of residents aged 16 and over. It covers health behaviours, health status, health service use and access, and social capital. With regard to health status, over 80 per cent of adults rated their health as excellent, very good or good. Indicators for health service use (p214-257) show that more than half of adults were covered by private health insurance. Just over 17% had presented to an emergency department in the previous 12 months. Care received was rated as excellent, very good or good by nearly 78% of adults presenting to emergency departments and over 88 per cent of patients admitted to hospital. [cited 2009 September 23]
Australia: The Healthiest Country by 2020 - The National Preventative Health Strategy
The National Preventative Health Strategy from the National Prevention Taskforce comprises seven strategic directions aimed at all Australians with the purpose of minimising the overload on the health and hospital systems and increasing the productivity and competitiveness of Australia's workforce. The seven strategic directions are reflected in strategies for tackling obesity, alcohol and tobacco; three risk factors with a total estimated cost of $6 billion per year to healthcare and $13 billion per year in lost productivity. Explicit aims include: halving and reversing the rise in overweight and obesity; reducing the prevalence of daily smoking to 10% or less; and reducing the proportion of Australians who drink at short-term and long-term risky levels. The strategy also aims to contribute to the 'Close the Gap' target for indigenous people.
You can read the report here . [cited 2009 September 23]
What Are People Talking About?
What is Medicare Select?
Medicare Select was an option for reforming the Australian health system that was outlined in the National Health and Hospital Reform Commission's final report (June 2009) . Public debate about Medicare Select has been mired by confusion and misinformation. A recent background note prepared by Anne-marie Boxall from the Parliamentary Library titled "What is Medicare Select?" was drafted to explain what the Medicare Select proposal is and how it would change the Australian health system if it were implemented.
The background note on Medicare Select can be found here [cited 2009 September 23]
New NHS hospital comparison website
The UK Department of Health has launched a web tool that will allow patients to rate and compare hospitals as they would on an internet comparison site. The hospital "scorecard" on the NHS Choices website will enable patients to read reviews on mortality rates, infection rates (including rates for MRSA and C. difficile), cleanliness, staff performance, quality of food, the extent to which patients were involved in decisions concerning their care and whether they would recommend the hospital to friends and family. Health secretary Andy Burnham believes that the system will 'allow patients to make the right choice of hospital' but representatives of the British Medical Association have expressed reservations about the simplistic nature of the data represented with vast amounts of information summarised to give one overall measure of hospital performance.
You can view the "Find and choose services" at www.nhs.uk [cited 2009 September 23]
The case for health reform
In this article, published in the Medical Journal of Australia, Steven Lewis and Stephen Leeder review the case for major health care reform. They argue that a relationship between health spending and health status and outcomes in rich countries does not exist because a 'lot of health care is not very good and not very efficient'. Waste and variations in practice are widespread with huge differences in the use and cost of health care among similar populations. The authors believe that increases in spending cannot definitively solve problems of access, quality or equity and point to examples where quality improvements have reduced rather than increased costs. They assert that the systems that do best are those which are 'attuned to, and centred on, the users of services rather than being organised for the convenience of providers' . In addition these systems focus on prevention with investment in programs that will defer or pre-empt costs.
The full article can be read here [cited 2009 September 21]
Improving quality and safety in hospitals - a practical guide
Enhancing Patient Care: A Practical Guide to Improving Quality and Safety in Hospitals by Ian Wolff and Sally Taylor from MJA books provides an "integrated set of quality improvement and risk management modules that can be used individually or in various combinations". Written by Australian Clinicians and based on their work, as Director of Medical Services and Clinical Risk Manager over nearly 20 years, in the Wimmera Health Care Group in rural Victoria, Australia, it provides a pragmatic framework that guides other health services through the relevant evidence and theory, down to fine details on practical quality, safety and risk management. The guide is endorsed by Bruce Barraclough, Chair, New South Wales Clinical Excellence Commission as "a marvellous resource document for everyone who is actively trying to improve care delivery".
Enhancing Patient Care: A Practical Guide to Improving Quality and Safety in Hospitals by Ian Wolff and Sally Taylor. MJA Books. ISBN: 978 0 9775786 6 5.
Forthcoming Events
The Menzies Centre for Health Policy: Policy for enhanced prevention in US and Australia: how much bang for the buck? Wednesday, 7 October 2009, 5.30pm University of Sydney.
Prevention makes sense! But does it make economic sense? Are the recommendations from the National Health and Hospital Reform Commission and the National Preventative Health Strategy sound investments? Or are there other approaches/recommendations worth considering? Are there lessons to be learnt from the current proposals for reform in the US? Guest Speakers: Dr Lesley Russell, Menzies Foundation Fellow and Research Associate, United States Studies Centre; Dr Garry Egger, Director, Centre for Health Promotion and Research; and Professor Glenn Salkeld, Head of the School of Public Health at the University of Sydney will consider these questions, moderated by Professor Stephen Leeder, Director, Menzies Centre for Health Policy.
Refreshments will be available from 5pm. Eastern Avenue Lecture Theatre, Eastern Avenue, University of Sydney (Map reference K5 on). RSVP: Email mchp@med.usyd.edu.au by Friday, 2nd October.
The Menzies Centre for Health Policy Annual Oration: How Preventable is Cardiovascular Disease? Tuesday, 13 October, 12.30pm, The Australian National University.
Dr Derek Yach, Vice President, Global Health Policy, Pepsi Co will ask: What will it take to reverse trends in cardiovascular disease? What lessons are applicable from developed countries? And, given our current state of knowledge about causes and the effectiveness of interventions: Is cardiovascular disease preventable within the next 50 years?
Venue: The Finkel Lecture Theatre The John Curtin School of Medical Research Building 131, Garran Road Acton Canberra (The Australian National University Campus). RSVP: to laura.vitler@anu.edu.au by Monday 5 October.
AHHA/AIHPS 2009 Congress Shaping up in Health: How does Australia become the world's best? 8-9 October 2009, Hotel Grand Chancellor, Hobart, Tasmania
The Australian Healthcare and Hospitals Association Congress is an opportunity to network with colleagues from across Australia and engage in a high-level discussion about healthcare policy with healthcare managers, policy writers, academic researchers and senior clinical staff. The congress will enable delegates to: learn how to create world-class services; explore what makes a high performing healthcare system; discuss the performance of Australia's health system; and compare Australia's outcomes nationally and internationally.
For further details and to register interest click here [cited 2009 September 23]
Multi-Level Modelling Master Class. Wednesday 21 October 2009, 9.30am - 4.30pm, University of Western Sydney, Campbelltown Campus
Professor Alastair Leyland, from the Medical Research Council Social and Public Health Sciences Unit in the UK, an international leader in multi-level modelling will be conducting a one-day master class on multilevel modelling in public health and health services research. The session is aimed at people working on multi-level modelling projects to present their projects and seek feedback and expert advice.
School of Medicine (Building 30), University of Western Sydney, Campbelltown Campus. Click Here for full details. [cited 2009 September 23]
5th HARC Forum: Monitoring variation in healthcare quality - an evidence base to improve healthcare - Lessons from the US Dartmouth Atlas Project. Wednesday 4 November 2009, 5 -7.30pm, Royal Prince Alfred Hospital.
Keynote Speaker Professor Elliott Fisher from the Dartmouth Atlas of Health Care will give an overview of the internationally leading Dartmouth Atlas Project. Over the past 20 years, the Dartmouth Atlas has documented glaring variations in how healthcare is delivered in the United States. This research has radically changed the way we think about effectiveness and efficiency of health care and has shaped the thinking and actions of US policymakers, clinicians, health service managers and researchers. Using the experience and research from Dartmouth Atlas, a panel of high profile health leaders will consider how it applies to the Australian health system and discuss how we can monitor variation healthcare quality within the current context of healthcare reform.
The Auditorium, Kerry Packer Education Centre, Royal Prince Alfred Hospital, Camperdown. Further details will be circulated shortly and registration is essential for attendance. More information can be obtained from Bea Brown: bea.brown@saxinstitute.org.au
Reforming Australia's health workforce conference. 23-24 November 2009, Sofitel, Wentworth, Sydney
A skilled workforce underpins Australia's health system. People represent over 70% of total health expenditure in Australia. Attend the event and discuss workforce reform issues such as: progress toward COAG driven national health workforce policy reform and implementation; recommendations on workforce policy stemming from the National Health and Hospitals Reform Commission and developing a sustainable, patient-centred health workforce. Click the link for the conference website [cited 2009 September 23]
HSRAANZ 6th Health Services and Policy Research Conference. 25-27 November 2009, Brisbane Convention and Exhibition Centre
This year's theme is 'Health Services Research - Reforming, Responding, Rewarding'. In Australia, the Health and Hospitals Reform Commission is considering options for restructuring the Australian Health System. And in New Zealand, while there is a sense of reform fatigue, many incremental changes and innovations in health services are continually being introduced. How can health service researchers respond to these current needs for health care and health system reform? Rewarding good performance necessitates performance measurement and monitoring. What is being done in Australia and New Zealand? And what can we learn from other countries? Conference website [cited 2009 September 23]
