Do patients have a say? A narrative review of the development of patient-reported outcome measures used in elective procedures for coronary revascularisation

PURPOSE

Patient-reported outcome measures (PROMs) capture health information from the patient's perspective that can be used when weighing up benefits, risks and costs of treatment. This is important for elective procedures such as those for coronary revascularisation. Patients should be involved in the development of PROMs to accurately capture outcomes that are important for the patient. The aims of this review are to identify if patients were involved in the development of cardiovascular-specific PROMs used for assessing outcomes from elective coronary revascularisation, and to explore what methods were used to capture patient perspectives.

METHODS

PROMs for evaluating outcomes from elective coronary revascularisation were identified from a previous review and an updated systematic search. The studies describing the development of the PROMs were reviewed for information on patient input in their conceptual and/or item development.

RESULTS

24 PROMs were identified from a previous review and three additional PROMs were identified from the updated search. Full texts were obtained for 26 of the 27 PROMs. The 26 studies (11 multidimensional, 15 unidimensional) were reviewed. Only nine studies reported developing PROMs using patient input. For eight PROMs, the inclusion of patient input could not be judged due to insufficient information in the full text.

CONCLUSIONS

Only nine of the 26 reviewed PROMs used in elective coronary revascularisation reported involving patients in their conceptual and/or item development, while patient input was unclear for eight PROMs. These findings suggest that the patient's perspective is often overlooked or poorly described in the development of PROMs.

Reasons why specialist doctors undertake rural outreach services: an Australian cross-sectional study

BACKGROUND

The purpose of the study is to explore the reasons why specialist doctors travel to provide regular rural outreach services, and whether reasons relate to (1) salaried or private fee-for-service practice and (2) providing rural outreach services in more remote locations.

METHODS

A national cross-sectional study of specialist doctors from the Medicine in Australia: Balancing Employment and Life (MABEL) survey in 2014 was implemented. Specialists providing rural outreach services self-reported on a 5-point scale their level of agreement with five reasons for participating. Chi-squared analysis tested association between agreement and variables of interest.

RESULTS

Of 567 specialists undertaking rural outreach services, reasons for participating include to grow the practice (54%), maintain a regional connection (26%), provide complex healthcare (18%), healthcare for disadvantaged people (12%) and support rural staff (6%). Salaried specialists more commonly participated to grow the practice compared with specialists in fee-for-service practice (68 vs 49%). This reason was also related to travelling further and providing outreach services in outer regional/remote locations. Private fee-for-service specialists more commonly undertook outreach services to provide complex healthcare (22 vs 14%).

CONCLUSIONS

Specialist doctors undertake rural outreach services for a range of reasons, mainly to complement the growth and diversity of their main practice or maintain a regional connection. Structuring rural outreach around the specialist's main practice is likely to support participation and improve service distribution.

Subsidies to target specialist outreach services into more remote locations: a national cross-sectional study

Objective Targeting rural outreach services to areas of highest relative need is challenging because of the higher costs it imposes on health workers to travel longer distances. This paper studied whether subsidies have the potential to support the provision of specialist outreach services into more remote locations. Methods National data about subsidies for medical specialist outreach providers as part of the Wave 7 Medicine in Australia: Balancing Employment and Life (MABEL) Survey in 2014. Results Nearly half received subsidies: 19% (n = 110) from a formal policy, namely the Australian Government Rural Health Outreach Fund (RHOF), and 27% (n = 154) from other sources. Subsidised specialists travelled for longer and visited more remote locations relative to the non-subsidised group. In addition, compared with non-subsidised specialists, RHOF-subsidised specialists worked in priority areas and provided equally regular services they intended to continue, despite visiting more remote locations. Conclusion This suggests the RHOF, although limited to one in five specialist outreach providers, is important to increase targeted and stable outreach services in areas of highest relative need. Other subsidies also play a role in facilitating remote service distribution, but may need to be more structured to promote regular, sustained outreach practice. What is known about this topic? There are no studies describing subsidies for specialist doctors to undertake rural outreach work and whether subsidies, including formal and structured subsidies via the Australian Government RHOF, support targeted outreach services compared with no financial support. What does this paper add? Using national data from Australia, we describe subsidisation among specialist outreach providers and show that specialists subsidised via the RHOF or another source are more likely to provide remote outreach services. What are the implications for practitioners? Subsidised specialist outreach providers are more likely to provide remote outreach services. The RHOF, as a formally structured comprehensive subsidy, further targets the provision of priority services into such locations on a regular, ongoing basis.

The epidemiology of pre-hospital potential spinal cord injuries in Victoria, Australia: a six year retrospective cohort study

BACKGROUND

Traumatic Spinal Cord Injury (TSCI) is relatively uncommon, yet a devastating and costly condition. Despite the human and social impacts, studies describing patients with potential TSCI in the pre-hospital setting are scarce. This paper aims to describe the epidemiology of patients potentially at risk of or suspected to have a TSCI by paramedics, with a view to providing a better understanding of factors associated with potential TSCI.

METHODS

This is a retrospective cohort study of all adult patients managed and transported by Ambulance Victoria (AV) between 01 January 2007 and 31 December 2012 who, based on meeting pre-hospital triage protocols and criteria for spinal clearance, paramedic suspicion or spinal immobilisation, were classified to be at risk of or suspected to have a TSCI. Data was extracted from the AV data warehouse, including demographic details, trauma aetiology, paramedic assessment, management and other event characteristics.

RESULTS

A total of 106,059cases were included in the study, representing 2.3 % of all emergency transports by AV. Subjects had a median age of 51 years (interquartile range; 29-78) and 52.4 % were males (95 % CI 52-52.7). Males were significantly younger than females (M: 43 years [26-65] vs. F: 64 years [36-84], p =0.001). Falls and traffic accidents were the leading causes of injuries, comprising 46.9 and 39.4 % of cases, respectively. Other causes included accidents due to sport, animals, industrial work and diving, as well as violence and hanging. 29.9 % of patients were transported to a Major Trauma Service (MTS). A proportion of 48.8 % of the study population met the Pre-hospital Major Trauma criteria.

CONCLUSION

This is the first study to describe the epidemiology of potential TSCI in Australia and is based on a large, state-wide sample. It provides background knowledge and a baseline for future research, as well as a reference point for future in policy. Falling and traffic related injuries were the leading causes of potential SCI. Future research is required to identify the proportion of confirmed TSCI among the potentials and factors associated with TSCI in prehospital settings.

The extra resource burden of in-hospital falls: a cost of falls study

OBJECTIVE

To quantify the additional hospital length of stay (LOS) and costs associated with in-hospital falls and fall injuries in acute hospitals in Australia.

DESIGN, SETTING AND PARTICIPANTS

A multisite prospective cohort study conducted during 2011-2013 in the control wards of a falls prevention trial (6-PACK). The trial included all admissions to 12 acute medical and surgical wards of six Australian hospitals. In-hospital falls data were collected from medical record reviews, daily verbal reports by ward nurse unit managers, and hospital incident reporting and administrative databases. Clinical costing data were linked for three of the six participating hospitals to calculate patient-level costs.

OUTCOME MEASURES

Hospital LOS and costs associated with in-hospital falls and fall injuries for each patient admission.

RESULTS

We found that 966 of a total of 27 026 hospital admissions (3.6%) involved at least one fall, and 313 (1.2%) at least one fall injury, a total of 1330 falls and 418 fall injuries. After adjustment for age, sex, cognitive impairment, admission type, comorbidity and clustering by hospital, patients who had an in-hospital fall had a mean increase in LOS of 8 days (95% CI, 5.8-10.4; P < 0.001) compared with non-fallers, and incurred mean additional hospital costs of $6669 (95% CI, $3888-$9450; P < 0.001). Patients with a fall-related injury had a mean increase in LOS of 4 days (95% CI, 1.8-6.6; P = 0.001) compared with those who fell without injury, and there was also a tendency to additional hospital costs (mean, $4727; 95% CI, -$568 to $10 022; P = 0.080).

CONCLUSION

Patients who experience an in-hospital fall have significantly longer hospital stays and higher costs. Programs need to target the prevention of all falls, not just the reduction of fall-related injuries.

Should suspected cervical spinal cord injury be immobilised?: a systematic review

BACKGROUND

Spinal cord injuries occur worldwide; often being life-threatening with devastating long term impacts on functioning, independence, health, and quality of life.

OBJECTIVES

Systematic review of the literature to determine the efficacy of cervical spinal immobilisation (vs no immobilisation) in patients with suspected cervical spinal cord injury (CSCI); and to provide recommendations for prehospital spinal immobilisation.

METHODS

Searches were conducted of the Cochrane library, CINAHL, EMBASE, Pubmed, Scopus, Web of science, Google scholar, and OvidSP (MEDLINE, PsycINFO, and DARE) databases. Studies were included if they were relevant to the research question, published in English, based in the prehospital setting, and included adult patients with traumatic injury.

RESULTS

The search identified 1471 citations, of which eight observational studies of variable quality were included. Four studies were retrospective cohorts, three were case series and one a case report. Cervical collar application was reported in penetrating trauma to be associated with unadjusted increased risk of mortality in two studies [(OR, 8.82; 95% CI, 1.09-194; p=0.038) & (OR, 2.06; 95% CI, 1.35-3.13)], concealment of neck injuries in one study and increased scene time in another study. While, in blunt trauma, one study indicated that immobilisation might be associated with worsened neurological outcome (OR, 2.03; 95% CI, 1.03-3.99; p=0.04, unadjusted). We did not attempt to combine study results due to significant heterogeneity of study design and outcome measures.

CONCLUSION

There is a lack of high-level evidence on the effect of prehospital cervical spine immobilisation on patient outcomes. There is a clear need for large prospective studies to determine the clinical benefit of prehospital spinal immobilisation as well as to identify the subgroup of patients most likely to benefit.

Computer simulation of improvements in hospital length of stay for rehabilitation patients

OBJECTIVE

To estimate the potential improvement in acute and rehabilitation hospital length of stay for rehabilitation patients from hypothetical scenarios that address barriers to patient flow.

DESIGN

Data about the duration of key processes for patients (n = 360) admitted to acute hospitals and subsequently transferred to inpatient rehabilitation in 2 wards in Melbourne, Australia were used to develop a computer simulation model.

SUBJECTS

Simulated patients.

METHODS

A computer model of length of stay was developed, validation checks performed and alternate care pathways simulated.

RESULTS

Almost all scenarios resulted in significant changes in the length of stay compared with baseline. The effect size for the changes was typically small to medium. The duration of the rehabilitation discharge barriers showed significant changes in all hypothetical scenarios. The effect size was smaller when changes were made to a single barrier, but larger when multiple barriers were changed simultaneously.

CONCLUSION

Health system modelling can provide information regarding potential improvements in length of stay from addressing barriers to patient flow affecting rehabilitation patients. This can inform reforms to models of care and assist with cost benefit analyses.

A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities

BACKGROUND

residential aged care facility (RACF) resident numbers are increasing. Residents are frequently frail with substantial co-morbidity, functional and cognitive impairment with high susceptibility to acute illness. Despite living in facilities staffed by health professionals, a considerable proportion of residents are transferred to hospital for management of acute deteriorations in health. This model of emergency care may have unintended consequences for patients and the healthcare system. This review describes available evidence about the consequences of transfers from RACF to hospital.

METHODS

a comprehensive search of the peer-reviewed literature using four electronic databases. Inclusion criteria were participants lived in nursing homes, care homes or long-term care, aged at least 65 years, and studies reported outcomes of acute ED transfer or hospital admission. Findings were synthesized and key factors identified.

RESULTS

residents of RACF frequently presented severely unwell with multi-system disease. In-hospital complications included pressure ulcers and delirium, in 19 and 38% of residents, respectively; and up to 80% experienced potentially invasive interventions. Despite specialist emergency care, mortality was high with up to 34% dying in hospital. Furthermore, there was extensive use of healthcare resources with large proportions of residents undergoing emergency ambulance transport (up to 95%), and inpatient admission (up to 81%).

CONCLUSIONS

acute emergency department (ED) transfer is a considerable burden for residents of RACF. From available evidence, it is not clear if benefits of in-hospital emergency care outweigh potential adverse complications of transfer. Future research is needed to better understand patient-centred outcomes of transfer and to explore alternative models of emergency healthcare.

Reducing the length of stay for acute hospital patients needing admission into inpatient rehabilitation: a multicentre study of process barriers

BACKGROUND

Patient flow is a major problem in hospitals. Delays in accessing inpatient rehabilitation have not been well studied.

AIMS

Measure the time taken for key processes in the patient journey from acute hospital admission through to inpatient rehabilitation admission in order to identify opportunities for improvement.

METHODS

Retrospective open cohort study. All patients admitted over 8- and 10-month periods during 2008 into two inpatient rehabilitation units in Melbourne, Australia. Main outcome measures were the duration of the following key processes: acute hospital admission until referral for rehabilitation, referral until assessment by the rehabilitation service, assessment until deemed ready for transfer to rehabilitation, ready for transfer until rehabilitation admission.

RESULTS

Three hundred and sixty patients were in the study sample (females = 186; 51.7%); mean age = 58.4 (standard deviation = 15.0) years. There was a median of 7 (interquartile range [IQR] 4-13) days from acute hospital admission till referral for rehabilitation, a median of 1 (IQR 0-1) day from referral till assessment, a median of 0 (IQR 0-2) days from assessment till deemed ready for transfer and a median of 1 (IQR 0-3) day from ready till admission into rehabilitation. Overall, patients spent 12.0% (804/6682) of their acute hospital admission waiting for a rehabilitation bed.

CONCLUSIONS

There are opportunities to improve the efficiency of key processes in the acute hospital journey for patients subsequently admitted to inpatient rehabilitation; in particular, reducing the time from acute hospital admission till referral for rehabilitation and from being deemed ready for transfer to rehabilitation till admission.

Is the increase in emergency short-stay admissions sustainable? Trends across Melbourne, 2000 to 2009

OBJECTIVES

To describe the trends in emergency admissions over 10 years in terms of volume, age-specific rates, hospital length of stay (LOS) and clinical reasons.

METHODS

A retrospective analysis of population-based linked Department of Health ED and hospital admission data for metropolitan Melbourne 1999/2000 to 2008/2009 was conducted. Outcome measures included: hospital admission numbers (total, single day/overnight, ≥2 days LOS); admission rates per 1000 person-years (total, single day/overnight, ≥2 days LOS); hospital LOS.

RESULTS

The volume of patients admitted to hospital through EDs rose by 56% over the 10 years to June 2009. The number of same day/overnight admissions rose by 60%, equating to a 6.1% average annual increase beyond that accounted for by demographic change (95% CI 5.7-6.5%). The volume of patients admitted for ≥2 days also increased; however, the admission rate per 1000 persons for these longer-stay patients declined over the decade by 9% (95% CI 5-12%). The most frequent discharge diagnoses were injury or poisoning, and disorders of the circulatory, respiratory or digestive systems. The numbers and mortality rate for ED admissions declined over the decade.

CONCLUSION

Emergency hospital admissions have risen over the last decade even after adjustment for population changes. There was a disproportionate rise in same day/overnight admissions, with overrepresentation of the elderly. This is possibly related to changes in ED models of care, including introduction of short-stay units, improved diagnostic and therapeutic capability, and risk-averse management to optimise safe discharge, within the context of time-based performance targets.

A review of hospital characteristics associated with improved performance

PURPOSE

The objective of this review was to critically appraise the literature relating to associations between high-level structural and operational hospital characteristics and improved performance.

DATA SOURCES

The Cochrane Library, MEDLINE (Ovid), CINAHL, proQuest and PsychINFO were searched for articles published between January 1996 and May 2010. Reference lists of included articles were reviewed and key journals were hand searched for relevant articles.

STUDY SELECTION

and data extraction Studies were included if they were systematic reviews or meta-analyses, randomized controlled trials, controlled before and after studies or observational studies (cohort and cross-sectional) that were multicentre, comparative performance studies. Two reviewers independently extracted data, assigned grades of evidence according to the Australian National Health and Medical Research Council guidelines and critically appraised the included articles. Data synthesis Fifty-seven studies were reported within 12 systematic reviews and 47 observational articles. There was heterogeneity in use and definition of performance outcomes. Hospital characteristics investigated were environment (incentives, market characteristics), structure (network membership, ownership, teaching status, geographical setting, service size) and operational design (innovativeness, leadership, organizational culture, public reporting and patient safety practices, information technology systems and decision support, service activity and planning, workforce design, staff training and education). The strongest evidence for an association with overall performance was identified for computerized physician order entry systems. Some evidence supported the associations with workforce design, use of financial incentives, nursing leadership and hospital volume.

CONCLUSION

There is limited, mainly low-quality evidence, supporting the associations between hospital characteristics and healthcare performance. Further characteristic-specific systematic reviews are indicated.

Epidemiologic merit of obese-years, the combination of degree and duration of obesity

This study aims to test the effect of combining the degree and the duration of obesity into a single variable-obese-years-and to examine whether obese-years is a better predictor of the risk of diabetes than simply body mass index (BMI) or duration of obesity. Of the original cohort of the Framingham Heart Study, 5,036 participants were followed up every 2 years for up to 48 years (from 1948). The variable, obese-years, was defined by multiplying for each participant the number of BMI units above 30 kg/m(2) by the number of years lived at that BMI. Associations with diabetes were analyzed by using time-dependent Cox proportional hazards regression models adjusted for potential confounders. The incidence of type-2 diabetes increased as the number of obese-years increased, with adjusted hazard ratios of 1.07 (95% confidence interval: 1.06, 1.09) per additional 10 obese-years. The dose-response relation between diabetes incidence and obese-years varied by sex and smoking status. The Akaike Information Criterion was lowest in the model containing obese-years compared with models containing either the degree or duration of obesity alone. A construct of obese-years is strongly associated with risk of diabetes and could be a better indicator of the health risks associated with increasing body weight than BMI or duration of obesity alone.

Demand at the emergency department front door: 10-year trends in presentations

OBJECTIVES

To measure the increase in volume and age-specific rates of presentations to public hospital emergency departments (EDs), as well as any changes in ED length of stay (LOS); and to describe trends in ED utilisation.

DESIGN, PATIENTS AND SETTING

Population-based retrospective analysis of Department of Health public hospital ED data for metropolitan Melbourne for 1999-00 to 2008-09.

MAIN OUTCOME MEASURES

Presentation numbers; presentation rates per 1000 person-years; ED LOS.

RESULTS

ED presentations increased from 550,662 in 1999-00 to 853,940 in 2008-09. This corresponded to a 32% rise in rate of presentation (95% CI, 29%-35%), an average annual increase of 3.6% (95% CI, 3.4%-3.8%) after adjustment for population changes. Almost 40% of all patients remained in the ED for ≥4 hours in 2008-09, with LOS increasing over time for patients who were more acutely unwell. The likelihood of presentation rose with increasing age, with people aged≥85 years being 3.9 times as likely to present as those aged 35-59 years (95% CI, 3.8-4.0). The volume of older people presenting more than doubled over the decade. They were more likely to arrive by emergency ambulance and were more acutely unwell than 35-59 year olds, with 75% having an LOS≥4 hours and 61% requiring admission in 2008-09.

CONCLUSION

The rise in presentation numbers and presentation rates per 1000 person-years over 10 years was beyond that expected from demographic changes. Current models of emergency and primary care are failing to meet community needs at times of acute illness. Given these trends, the proposed 4-hour targets in 2012 may be unachievable unless there is significant redesign of the whole system.

The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015

OBJECTIVE

To measure the growth in emergency ambulance use across metropolitan Melbourne since 1995, to measure the impact of population growth and ageing on these services, and to forecast demand for these services in 2015.

DESIGN AND SETTING

A population-based retrospective analysis of Ambulance Victoria's metropolitan emergency ambulance transportation data for the period from financial year 1994-95 to 2007-08, and modelling of demand in the financial year 2014-15.

MAIN OUTCOME MEASURES

Numbers and rates of emergency ambulance transportations.

RESULTS

The crude annual rate of emergency transportations across all age groups increased from 32 per 1000 people in 1994-95 to 58 per 1000 people in 2007-08. The rate of transportation for all ages increased by 75% (95% CI, 62%-89%) over the 14-year study period, representing an average annual growth rate of 4.8% (95% CI, 4.3%-5.3%) beyond that explained by demographic changes. Patients aged ≥ 85 years were eight times (incident rate ratio, 7.9 [95% CI, 7.6-8.3]) as likely to be transported than those aged 45-69 years over this period. Forecast models suggest that the number of transportations will increase by 46%-69% between 2007-08 and 2014-15, disproportionately driven by increasing usage by patients aged ≥ 85 years.

CONCLUSIONS

These findings confirm a dramatic rise in emergency transportations over the study period, beyond that expected from demographic changes. Rates increased across all age groups, but more so in older patients. In the future, such acceleration is likely to have major effects on ambulance services and acute hospital capacity. This calls for further investigation of underlying causes and alternative models of care.

Increasing utilisation of emergency ambulances

BACKGROUND

Increased ambulance utilisation is closely linked with Emergency Department (ED) attendances. Pressures on hospital systems are widely acknowledged with ED overcrowding reported regularly in the media and peer-reviewed literature. Strains on ambulance services are less well-documented or studied.

AIMS

To review the literature to determine the trends in utilisation of emergency ambulances throughout the developed world and to discuss the major underlying drivers perceived as contributing to this increase.

METHOD

A search of online databases, search engines, peer-reviewed journals and audit reports was undertaken.

FINDINGS

Ambulance utilisation has increased in many developed countries over the past 20 years. Annual growth rates throughout Australia and the United Kingdom are similar. Population ageing, changes in social support, accessibility and pricing, and increasing community health awareness have been proposed as associated factors. As the extent of their contribution has not yet been established these factors were reviewed.

CONCLUSION

The continued rise in utilisation of emergency ambulances is placing increasing demands on ambulance services and the wider health system, potentially compromising access, quality, safety and outcomes. A variety of factors may contribute to this increase and targeted strategies to reduce utilisation will require an accurate identification of the major drivers of demand.

The number of years lived with obesity and the risk of all-cause and cause-specific mortality

BACKGROUND

The role of the duration of obesity as an independent risk factor for mortality has not been investigated. The aim of this study was to analyse the association between the duration of obesity and the risk of mortality.

METHODS

A total of 5036 participants (aged 28-62 years) of the Framingham Cohort Study were followed up every 2 years from 1948 for up to 48 years. The association between obesity duration and all-cause and cause-specific mortality was analysed using time-dependent Cox models adjusted for body mass index. The role of biological intermediates and chronic diseases was also explored.

RESULTS

The adjusted hazard ratio (HR) for mortality increased as the number of years lived with obesity increased. For those who were obese for 1-4.9, 5-14.9, 15-24.9 and ≥ 25 years of the study follow-up period, adjusted HRs for all-cause mortality were 1.51 [95% confidence interval (CI) 1.27-1.79], 1.94 (95% CI 1.71-2.20), 2.25 (95% CI 1.89-2.67) and 2.52 (95% CI 2.08-3.06), respectively, compared with those who were never obese. A dose-response relation between years of duration of obesity was also clear for all-cause, cardiovascular, cancer and other-cause mortality. For every additional 2 years of obesity, the HRs for all-cause, cardiovascular disease, cancer and other-cause mortality were 1.06 (95% CI 1.05-1.07), 1.07 (95% CI 1.05-1.08), 1.03 (95% CI 1.01-1.05) and 1.07 (95% CI 1.05-1.11), respectively.

CONCLUSIONS

The number of years lived with obesity is directly associated with the risk of mortality. This needs to be taken into account when estimating its burden on mortality.

Systematic review of trends in emergency department attendances: an Australian perspective

Emergency departments (EDs) in many developed countries are experiencing increasing pressure due to rising numbers of patient presentations and emergency admissions. Reported increases range up to 7% annually. Together with limited inpatient bed capacity, this contributes to prolonged lengths of stay in the ED; disrupting timely access to urgent care, posing a threat to patient safety. The aim of this review is to summarise the findings of studies that have investigated the extent of and the reasons for increasing emergency presentations. To do this, a systematic review and synthesis of published and unpublished reports describing trends and underlying drivers associated with the increase in ED presentations in developed countries was conducted. Most published studies provided evidence of increasing ED attendances within developed countries. A series of inter-related factors have been proposed to explain the increase in emergency demand. These include changes in demography and in the organisation and delivery of healthcare services, as well as improved health awareness and community expectations arising from health promotion campaigns. The factors associated with increasing ED presentations are complex and inter-related and include rising community expectations regarding access to emergency care in acute hospitals. A systematic investigation of the demographic, socioeconomic and health-related factors highlighted by this review is recommended. This would facilitate untangling the dynamics of the increase in emergency demand.

Final report of the National Health and Hospitals Reform Commission: will we get the health care governance reform we need?

The National Health and Hospitals Reform Commission (NHHRC) has recommended that Australia develop a "single health system", governed by the federal government. Steps to achieving this include: a "Healthy Australia Accord" to agree on the reform framework; the progressive takeover of funding of public hospitals by the federal government; and the possible implementation of a consumer-choice health funding model, called "Medicare Select". These proposals face significant implementation issues, and the final solution needs to deal with both financial and political sustainability. If the federal and state governments cannot agree on a reform plan, the Prime Minister may need to go to the electorate for a mandate, which may be shaped by other economic issues such as tax reform and intergenerational challenges.

Measuring quality

It is no longer sufficient for health care professionals to provide high quality health care, they must also be able to demonstrate that they are meeting and often exceeding quality targets. Quality indicators (QIs) provide a means of measuring and assessing quality, however there are advantages and disadvantages of indicator measurement. Further, the clinical perspective needs to be balanced against managerial control when developing valid, reliable, sensitive and specific QIs. While indicators do not represent a perfect measurement device, they may provide a useful tool for improving patient safety and meeting community expectations.

Riding the wave: current and emerging trends in graduates from Australian university medical schools

The number of domestic graduates from Australian medical schools is set to increase by 81% in 7 years, from 1348 in 2005 to 2442 by 2012. Including international students, medical school graduates will total almost 3000 by 2012. Planning must begin now to ensure that the significant flow-on effects of these increases are managed effectively. Most urgently, postgraduate medical training will require a substantial injection of resources to expand opportunities for clinical training, without compromising quality. Patterns of career choice by medical graduates and workforce supply levels must be monitored to ensure responsiveness to the effects of substantially larger, and more diverse, graduate cohorts.

More doctors, but not enough: Australian medical workforce supply 2001-2012

OBJECTIVE

To project the future size of the Australian medical workforce, from 2001 to 2012.

DESIGN AND SETTING

Stochastic simulation modelling of the Australian medical workforce, taking into account recent increases in medical school capacity and trends in the intake of foreign graduates.

MAIN OUTCOME MEASURES

Number of full-time equivalent (FTE) medical practitioners per 100,000 persons within various occupation groups from 2001 (baseline) to 2012.

RESULTS

The total medical workforce was projected to rise from 53,384 in 2001 to 67,659 by 2012 (95% CI, 63,924-71,036). On a per capita basis, the number of FTE clinicians was projected to rise from 331 per 100,000 persons in 2001 to 382 (95% CI, 359-403) per 100,000 persons in 2012. The general practice workforce was projected to fall from 133 FTE general practitioners per 100,000 persons in 2001, to 129 per 100,000 persons in 2003, and then remain at around this level through to 2012. The specialist workforce was projected to show steady growth, rising from 162 FTE specialists per 100,000 persons in 2001 to 206 (95% CI, 194-218) per 100,000 persons in 2012.

CONCLUSIONS

The general practice workforce is likely to face continued chronic shortages, necessitating innovative policy responses to ensure that the community's need for primary medical care is met. Retirement rates are a key determinant of workforce supply, suggesting a need to encourage general practitioners to remain active as long as they remain effective. Further refinement of stochastic models will help facilitate a more proactive approach to workforce planning.

Time for a new approach to medical workforce planning

There are concerns that Australia is facing an impending shortage in the medical workforce, and there are significant changes occurring in key determinants of medical workforce supply and demand. To date, workforce planning has not taken into account the full range of dynamic variables that are involved, nor accounted for their inherent uncertainty and complex interactions. Future planning will require more careful monitoring and dynamic modelling within a full healthcare system perspective.

The price of choice: private health insurance in Australia

Private Health Insurance (PHI) is an integral part of the financing of the Australian health care system. PHI is popular and has strong political support because it is perceived to give choice of access and responsiveness. However, in the past increasing premiums have led to a progressive decline in membership. A package of reforms by the Commonwealth Government in support of the private health insurance has reinvigorated the industry over the last three years. Some strategies for achieving a sustainable PHI industry are described. The key challenge is to control claims cost to maintain affordable premiums. Many techniques to do this compromise choice and challenge the very rationale for purchasing the product. Funds and providers will have to establish a new level of relationship to meet this challenge.

EBM in healthcare: management and policy

The nature of policymaking often precludes a significant role for formal evidence-based practice. Management practice is also bereft of formal evidence and appears unlikely to change because of the methodological constraints on collecting good evidence. Despite this, policymakers and managers are keen to promote evidence-based clinical practice. This, in part, reflects rational management's desire to standardise the clinical process and develop the profession's accountability to the management hierarchy. To the extent that clinical practice is dependent on organisational settings, this push is inevitable. Widespread and persistent small-area variation in clinical practice, and concern over apparent high levels of avoidable error, make doctors vulnerable to these efforts to standardise clinical practice.

Casemix payment in the real world of running a hospital

The Victorian casemix funding initiative has achieved initial success in implementing massive budget cuts while increasing hospital throughput and reducing waiting lists. For hospitals to survive, the relationship between casemix and resource use must be managed and this can only be achieved by the involvement of clinicians. With effective information systems and accommodating clinicians, games to maximise casemix, and hence revenue, will undoubtedly emerge. Side effects may include reduced access to "unprofitable" services, increasing pressure on "unprofitable" clinicians and the wooing of "profitable" ones, increasing difficulty in delivering continuity of care and the politicisation of the diagnosis-related groups pricing system. In the end, State governments will be left with a complex control system without resolving the fundamental dilemma inherent in being both the provider of hospital care and the payer.

Drug and therapeutics committees: the relationships among structure, function, and effectiveness

Reported are the results of a national study of Australian hospitals that assessed the effectiveness of drug and therapeutics committees (DTCs), identifies factors that influence effectiveness, and recommends methods to improve effectiveness. Data were collected by questionnaires sent to 184 hospital directors of pharmacy and a subset of 53 chairpersons of DTCs. Response rates were 88.6% and 84.9%, respectively. Membership, chairperson, secretary, meeting frequency, and decision-making functions were analysed by hospital bed numbers and compared with standard accepted literature criteria and previous study findings. A comparison of pharmacist and chairperson perception as to the weakest aspect of DTCs in attaining rational therapy revealed widely differing views, based on factors outside respondents' own control. Perceptions of resources required to overcome DTC weakness also varied between the two groups. No statistically significant association was found between the assessment of outcome of DTC activities (influence on pharmacy management, hospital policy, medical management, and prescribing) and structural variables such as DTC objectives, chairperson, reporting relationship, meeting frequency, and hospital size or type. The results challenge widely held assumptions of the association between DTC effectiveness and structural variables. Further study of structural and cultural variables, which might determine effectiveness, is required.

The design and implementation of a management information system for Australian public hospitals

Existing management information systems (MIS) in hospitals are often inadequate. This has occurred because of a variety of antecedents, including past funding mechanisms, organisational structure and the accepted role of management. A variety of new pressures, including demands for increased accountability, greater resource control and changing relationships between physicians and hospitals are demanding improved MIS to enable the hospital to manage. This paper explores these influences on past and future hospital MIS. It describes the design of a MIS that enables patient care to be costed in clinically meaningful ways. Patient costs may be aggregated to cost specific diagnoses and procedures, Diagnosis Related Groups (DRG), a clinician's case load, a clinical unit or a division. The information can be used for clinical budgeting, flexible budgeting, utilisation review and quality assurance.

Nurse managers and budgeting: professional/bureaucratic conflict?

Professional/bureaucratic conflict theory suggests that the extent to which nurse managers use management control systems will depend on whether their goal orientation is to system rather than output or derived goals. This article examines the use of budgeting as a management control strategy, in relation to the goal orientation of nurse managers, in four large teaching hospitals. The goal orientations and use of budgeting by nurse managers is also compared with those of physician managers and other sub-unit managers. The results indicate that nurse managers appear to be developing their goals of professionalization without a diminution of their organizational focus or their orientation towards providing a high standard of patient care.

Models for costing patient care services. Part 2: Costing organ imaging services

This is the second of a series of articles describing the cost models developed as part of the new computerised Clinical Information System (CIS) at the Queen Victoria Medical Centre campus of the Monash Medical Center in Melbourne. The first article in this series described the costing of diagnostic laboratory services. This paper provides a brief overview of the CIS and describes the costing of services in the Medical Imaging Division.

Improving patient care and pharmacy management: the effect of hospital formularies

A study of the organizational features and implementation procedures associated with formulary use in major acute-care hospitals throughout Australia was undertaken. Data were collected via a questionnaire mailed to 57 directors of pharmacy. An 86-percent response was obtained. A high proportion of formularies was found to rate poorly in terms of organizational features (e.g., content, compilation methods, format) and process variables (e.g., effectiveness as a communication document, prescribing aid, or management tool). Methods of improving formulary effectiveness are outlined in the context of practical and normative research, including improving the quality of drug therapy, use of formularies in cost control, and improving user acceptance. The results confirm previous research showing that methods of improving organizational features and implementation procedures associated with formulary compilation and use are neither widely applied nor widely known. There is an urgent need to reassess the usefulness of formularies and improve their effectiveness by adopting recommendations resulting from past research.