This, however, is something else. In case it’s been a long week….

Click here to view the embedded video.

I will spare you the colorectal surgeon song.

Well, maybe not.

Click here to view the embedded video.

There is plenty more where they came from, but I will stop now…

But at least we now have some idea of what sort of questions we should be asking, thanks to a report released this week by the Australian Institute of Health and Welfare, called Towards national indicators of safety and quality in health care (and available here).

The Australian Commission on Safety and Quality in Health Care funded the Institute to develop safety and quality indicators for various health settings, including primary care and community health care services, hospitals, specialised health services (such as palliative care, defence health services etc), and residential aged care.

Now that we at least know the questions to ask, we’re somewhat further down the path towards open public reporting of health service performance.

The report notes, however, that the issue remains extremely contentious and that “Australia has yet to follow the lead of countries such as the United States of America and United Kingdom which have adopted detailed regular public reporting at the provider level”.

While there are many concerns about the impact and usefulness of open public reporting, the report says it could have two purposes: to provide transparency and to inform decision-making about overall priorities and system-level strategies for safety and quality improvement; and to inform quality improvement activities of service providers.

It cites one study comparing the degree to which performance information stimulated quality improvement activity in hospitals if it was publicly reported or if hospitals received private reports.

The authors reported finding strong evidence that “….making performance information public stimulates quality improvement in the areas where performance is reported to be low. Since quality improvement efforts among the public-report hospitals appear to be significantly greater than in hospitals given only private reports, there is added value to making performance information public.”

To give you an idea of the indicators suggested by the report, they include:

For primary care and community health services:

• General practices with a register and recall system for patients with chronic disease
• People with moderate to severe asthma who have a written asthma action plan
• Mental health care plans in general practice
• Annual cycle of care for people with diabetes mellitus

For hospitals:

• Assessment for risk of venous thromboembolism in hospitals
• Pain assessment in the emergency department
• Stroke patients treated in a stroke unit
• Complications of transfusion
• Health care associated infections acquired in hospital
• Adverse drug events in hospitals
• Malnutrition in hospitals and residential aged care facilities
• Pressure ulcers in hospitals and residential aged care facilities

For specialised health services:

• Post-discharge community care for mental health patients
• Functional gain achieved in rehabilitation
• Multi-disciplinary care plans in sub-acute care

For residential aged care:

• Oral health in residential aged care
• People receiving a medication review
• Falls resulting in patient harm in hospitals and residential aged care facilities

The report note that indicators already exist for specific types of services, including Key Performance Indicators for Public Sector Mental Health Services, Australian Council on Healthcare Standards clinical indicator sets, for specific population groups such as the Aboriginal and Torres Strait Islander Health Performance Framework, and the COAG National Healthcare Agreement Performance Indicators.

Now that we have all these questions to ask, when will the answers be made available to the public? And will we make best use of them? So many questions searching for answers…

In my view the campaign was undermined, before I even got to reading the detail, by its title, Grandma’s not happy. Tacky, tacky manipulation.

As you may have heard in the news in the last few days, the Government has struck back, via this ALP clip on You Tube, subtitled, Protect Peoples’ Sight, Not Ophthalmologists Wallets…

Click here to view the embedded video.

It would be interesting to hear what GPs and other health professionals think of the cutbacks.  Perhaps an interesting study for someone to do?

I suspect there may not be much sympathy in many circles; I’ve heard a few GPs muttering along the lines “about time”. One suggested that the Government should now have a look at the dermatologists….

Update (on 1 Oct).

Now the Vic branch of the AMA has struck back. It really is turning into You Tube at 20 paces…

Click here to view the embedded video.

Instead, he seems to have added fuel to the fire – at least, according to Dr Ken Harvey, who argues that the Government and TGA are making things all too cosy for the industry, at the expense of the public interest.

Harvey writes:

“Australian Medicines Policy is meant to be based on partnership with all the players, including consumers and health professionals. It is not meant to be a bilateral relationship between the Therapeutic Goods Administration and industry.

Yet, once again (see Mark Butler’s press release):

“The TGA is meeting with all the therapeutic industry associations next week to discuss their respective codes and consider potential strategies for a way forward.”

and Mr Butler said:

“I look forward to receiving advice on industry agreed options for working together to strengthen codes of conduct, provide a level playing field, and ensure that self-regulation retains public and Government confidence.”

In my opinion, these bilateral consultations between the TGA and industry are not in accord with the spirit of Australian Medicines Policy and the debate on ethical promotion must be opened up to include health professional and consumer groups as well.

Self-regulation is ultimately self-serving and these matters should not be left solely to the pharmaceutical industry.

If you agree, I suggest you communicate your concern to Mark Butler (as I have done).”

• Dr Ken Harvey is Adjunct Senior Research Fellow, School of Public Health, La Trobe University

The PM cited Australian research, recently published in the New England Journal of Medicine and reported in Crikey,  which found, he said, “that a commonly available treatment for fractures of the bones of the spinal cord was in fact no better than doing nothing at all”.

The PM said the Government was “keen to explore in conjunction with private health insurers and our research community” an NHMRC suggestion that treatments, therapies and devices which are not backed by evidence should be evaluated.

In the light of the PM’s enthusiasm for ensuring that health funding is well spent, I wonder whether he and his office are familiar with the work that was being done along these lines by the Royal Australasian College of Surgeons in evaluating surgical techniques.

Professor Guy Maddern, a surgeon who has been a driving force behind this work, writes of his great frustration at the Government’s apparent lack of support for the work:

“The recent publications in the New England Journal of Medicine describing the results of vertebroplasty highlight the problem of introduction of new surgical technologies.

Whenever a new procedure is assessed, particularly in its early stages, it is often difficult to prove that it is a superior step forward than existing technologies. This is in part because it is difficult to conduct the trials necessary to prove benefit.

Rather than rejecting a procedure because the evidence fails to be compelling, these two recent publications in the New England Journal of Medicine highlight the need for careful and assessed introduction of new technologies and procedures into surgical practice.

It is a great shame that the Australian Commonwealth Government does not greatly value assessment of procedures, particularly if they are not associated with a new Medicare item. While great efforts are put into assessing introduction of new drugs, substantial efforts are put into assessing new devices, much less effort and energy is put into the assessment of new procedures which often represent an alteration, which may be significant, of existing procedures.

It has been a great disappointment to the Royal Australasian College of Surgeons that the Commonwealth Government has not felt the need to continue to support the Australian Safety and Efficacy Register of New Interventional Procedures in Surgery.

This organisation, run by the College of Surgeons, attempts to look at new procedures that are introduced without the necessity for new Medicare item numbers. It may be that the alteration of a length of bowel, an angle of suturing or the use of existing devices in new and novel ways can bring enormous benefits but also potentially enormous harm to patients.

This desperately needs to be assessed and reported on, but explaining this to the Government at this time is a difficult and frustrating experience.

The reporting of this recent study highlights the difficulties in assessing new technologies but does not excuse the process from occurring. Hopefully it will provide further evidence to the health authorities that such activities are desperately needed within our health system.”

More info about the scheme is available in this British Medical Journal article.

Writing from Washington, health policy analyst Dr Lesley Russell says the studies are big news there, especially with the Presidential focus on health reform. The devices industry will fight hard to retain a multi-million dollar market, she says:

“It is very interesting to look at the response to the publication of these studies in the US, where one of the arguments raging around the health care reform legislation under consideration in the Congress is government funding of comparative effectiveness research and the use to which the data generated might be put.

President Obama and health and economic policy experts have been calling for just these kinds of studies as a means of controlling health costs and ensuring better health outcomes and the House bill has $1.1 billion to establish a Center for Comparative Effectiveness Research.

Opponents see this as Big Brother, in the form of the government entering the health arena, making decisions that will deprive patients of choice, ration health care and result in ‘socialized medicine’.  The UK National Institute for Health and Clinical Excellence (NICE ) is definitely not seen as nice by these people, who are apparently happy to see decisions about what treatment they get made on the basis of bank balance or the profit motives of their health insurer.

The number of vertebroplasty procedures in the US has doubled in the past six years.  Last year 73,000 people had the treatment which costs $2,500 to $3,000 plus $1,000 – 2,000 for an MRI.  This procedure cost Medicare (the government-funded health care program for people aged 65 and over) $21 million.  The total US market in  vertebroplasty had a value of about $45 million in 2008 and is projected to grow annually at a rate of 13.5 percent.

There is even less data on the effects of kyphoplasty, which involves pumping the vertebra with a balloon to restore its shape before injecting cement, and which has a much larger market, estimated at more than $500 million a year.

But this is now where the US situation is headed, with the industry already out in the media emphasizing how kyphoplasty is different.

There is a comparative study of the two procedures underway, funded by the manufacturers, but results are apparently some way off.  There are some ten US medical device companies who are involved in this field, and the early indications are that they will not cede this profitable arena without a tough fight.

In the meantime, who should make the decisions about continued funding of this treatment and on what basis?

One of the researchers on the US paper has said that people who want vertebroplasty should still be able to get it – but only if they enter a clinical trial that collects data on every case.”

• Lesley Russell is Menzies Foundation Fellow at the Menzies Centre for Health Policy University of Sydney/Australian National University and Research Associate, US Studies Centre, University of Sydney

Below you can read some more suggestions for the Commission from several Croakey contributors, but first have a look at how much further the debate on hospital performance has advanced in some other countries.

In the UK, patients contemplating heart surgery can go to this website, for example, to examine the relative performance of hospitals.

In the US, this article from USA Today links to sites allowing patients to compare death rates for heart attack, heart failure and pneumonia for more than 4,400 hospitals.

Meanwhile back to the Productivity Commission:

Gordon Gregory from the National Rural Health Alliance would also like to see the inquiry consider:

• What is the relative role of public and private hospitals in ensuring that the ‘mainstream’ health system provides culturally safe and appropriate care to Aboriginal and Torres Strait Islander people? (ie what is their relative record on employing Aboriginal liaison offfcers; Aboriginal Health Workers; and in providing supported employment for Aboriginal nurses and interns?)

• Where private hospitals exist in regional areas, are they more or less part of the de facto primary care system than public ones? [hospitals doing primary care isn’t a good idea but needs must where there are no primary care providers. Are, for example, Catholic hospitals doing more or less of this than the public ones?]

• If one accepts the notion of a rural medical deficit (ie the extent to which rural and remote folks miss out on using Medicare), what is the extent of the rural and remote hospital deficit?  (This is not so much a matter of public/private as metropolitan/rural and remote, but there may be some angles for the Commission to consider)

***

Associate Professor Merrilyn Walton, Director of Patient Safety at the University of Sydney:

The first two terms of reference for the Productivity Commission’s current inquiry have merit but I agree with Melissa Sweet that they are indeed narrow.

Terms of Reference 1: Comparative hospital and medical costs for clinically similar procedures performed by public and private hospitals

Variation of costs is not the only issue for patients, variation in the provision of health care is also a significant issue for patients. A significant amount of variation is caused by differences in practice between providers of health care rather than differences between groups of patients. Research shows substantial levels of inappropriate care including under and over treatment.

Terms of Reference 2: The rate of hospital-acquired infections by type, reported by public and private hospitals

We do need to publish infection rates but the bigger issue is to minimise the transmission of infection in all health care environments. World expert on system failure James Reason says that breaches of infection control are routine in health care and equate to an intentional violation. We need to change the culture in health care as well as collect data.

***

Patrick Bolton, a senior public hospital manager, would like the Commission to consider these two points:

1. Turning the Commission’s question around a bit: Which bits of the healthcare system are best provided publicly, and which privately?

Whilst the evidence is not strong, my understanding is that not for profit hospitals (I use this term because much of the data come from North America and therein lies a comparison issue) deliver better outcomes than for profit ones. Outcome is of course only half of the efficiency story(!)

The interim report of the NHHRC seemed to accept that the private sector might be a better funder/purchaser of health, with not much analysis of the alternatives at that level or evidence that I recall, but there is an important question there.

I would like to see the role of the private sector in health capital management further discussed: This is a separate set of skills from health service provision. In my experience it is not generally well developed in the public health sector and might be better provided privately.

One advantage of such an approach is that it changes the incentives around flogging equipment until it breaks as often happens under public sector priority setting, because the cost is sunk and so the incentive is to drive the private provider to provide good capital.

2. I refer you to “The Science of Health Care Reform” RH Brook JAMA 301(23)2486-7 which I found through the Hospital Alliance for Research Collaboration newsletter.

This is a short and stimulating review of the reason for the gap between health expenditure and outcome, which has to be a concern of anyone with an interest in efficiency.

Essentially it attributes the gap to poor quality (ie doing things wrong) and poorly targeted interventions (doing the wrong thing). If this is correct then (a) one might expect the private sector to be more distorted than the public sector by incentives to provide inappropriately targeted services, but (b) the dichotomy between public and private might be looking at the wrong questions entirely.

Perhaps the question should really be how do we ensure that we do the right things right in any setting?

Certainly Brook says that high level policy approaches, which must include the public-private balance, are too crude to address the problem that he has identified.
***

A health policy expert who did not want to be identified offers the following comment to the Commission:

Private hospitals tend to have a much lower level of quality improvement activity, such as audits of series of procedures (eg looking at rates of deep surgical infections, or deaths within 7 days of an anaesthetic), or data driven improvement projects. It would be interesting to compare participation in quality activities.

****

Professor, Chris Baggoley, CEO, Australian Commission on Safety and Quality in Healthcare adds:

What I can say is that we have found the private sector very willing to take on and implement the safety and quality initiatives from our work that Ministers have endorsed, across the full range of these initiatives, including the Australian Charter of Healthcare Rights.

***

Michele Kosky, Health Consumers Council WA:

We would be very interested in seeing a comparison of the accurate reporting of adverse incidents in public and private hospitals, the overt commitment to patient safety in public and private hospitals, the involvement of patients and their families in the reduction of  unintended medical harm in public and private hospitals, and the adoption of the open disclusure standard in public and private hospitals.

***

Emeritus Professor Kerry Goulston, University of Sydney:

I like and agree with Croakey’s points. I strongly agree that the Commission’s terms of reference are too narrow.

Whilst nearly half of elective and day surgery is done in private hospitals, there  are not many private Emergency Departments. And relatively little training of healthcare workers occurs  in the private sector   There are some notable exceptions – Carina and Epworth in Melbourne, and Greenslopes in Brisbane.

We really need more medical students in private hospitals – patients accept them and it exposes students to private hospital medicine.

**
Robert Wells, Director Menzies Centre for Health Policy, Director Australian Primary Health Care Research Institute, ANU

Broadly speaking, there can be three possible findings from the inquiry:

1.    no appreciable difference between private &  public;
2.    private generally performs better against the areas of inquiry;  or
3.    public performs better.

If the answer is 1, then we probably can just muddle along as we are
If the answer is 2, then should we privatise all hospitals?
If the answer is 3, then why would we continue to subsidise the private sector via PHI measures?

Therefore the really pertinent question is: what do the study’s creators intend for it to find? (bearing in mind the maxim that one never sets up an inquiry withiout first knowing what the answer will be).

He writes:

“Any assessment of the public and private sector needs to look at a range of initiatives not only home grown but also being assessed internationally.  One such initiative that is gaining currency within the United States is Pay for Performance (PfP).

This brings in the concept that the care provided to a patient should be a total package of care and not based on adding on costs for complications or additional management interventions that may or may not have any genuine value.  For individuals, appropriate volumes of surgery on an appropriate range of patients, this system seems to offer great promise.  It also will dissuade practitioners who have poor results from continuing with the procedure as it will be expensive to them and expensive to the hospital.

The problem with such initiatives, of course, is the concern that more complex cases may not receive treatment because of their potential additional cost.  This, however, does not at this stage appear to be a major issue within the United States and providing the fundamental fee structure is appropriate, should average over the range of patients treated by competent hospitals and practitioners.

It certainly warrants attention, particularly in a system based on a fee for service structure.  This helps mitigate against over-servicing or poor practice.

Within the teaching context, public hospitals are well known to be expensive institutions for an episode of care, primarily because of the delays and inefficiencies associated with a teaching environment.  This needs to be carefully considered when comparing with private hospitals.   However, it also is an opportunity for private hospitals to demonstrate that they may be a more efficient and appropriate teaching venue for particularly surgical procedures.  It would be important to specifically look at private hospitals that have a significant and established teaching programme to see how these costs are being managed and whether or not lessons can be learnt from the public system in the way in which the private system delivers its undergraduate and postgraduate teaching.

For any health system to remain efficient and relevant, it needs to be relying on the evidence that is available for the procedures it performs.   What is the evidence that evidence-based practice is occurring in either our public or our private hospitals?   And if it is demonstrated to be occurring, are there benefits and efficiencies that flow from it?   This would be an important area for the Productivity Commission to consider in its review.

Finally, the great concern that exists within the public sector is the time patients have to wait until appropriate care is given.   This is made of up two components. The time from a consultation being booked and actually delivered which can, in some cases, be months or years, and the time that the patient goes onto a waiting list and waits until subsequent surgery is provided.  It would be important to look at the differences that occur to patients managed in the public system and the private system and to assess whether or not there is, in fact, an important difference between the time patients wait.   No doubt the private is quicker in delivering care but does this have relevant and important advantages for patients?

These are the challenges the Productivity Commission should be wrestling with, rather than the somewhat superficial terms of reference it currently has.”

On one hand, this is understandable – if everyone was hitting the headlines, complaining about the lack of resourcing to their particular area, then this could quickly lead to distortions in how funds are spent (as does indeed happen from time to time). Not to mention the political embarrassment this might cause.

On the other hand, this suppression of debate – enforced through endless protocols, employment contracts and other tactics, including bullying – is not healthy. It inhibits open discussion about the complexities of issues and challenges facing the system, and keeps the general public in the dark about what is, after all, meant to be a public service.

Those are just a few of the reasons why I’m delighted that a surgeon with a long commitment to the public sector, Professor Guy Maddern from Adelaide, has begun a new feature in the Crikey bulletin – Diary of a Surgeon. It records the life of a clinical director at St Anywhere. St Anywhere may be fictitious but the events and issues are real.

It will run every few weeks, if all things go according to plan, and will also be archived here in a single document.

Next step – anyone interested in writing a warts-and-all diary of a hospital boss or a public health manager? Or about life inside a health minister’s office?  I can’t make any promises on behalf of Crikey, but Croakey would be very happy to publish such accounts…

“The nature and content of health care needs to be constantly reviewed.   This remains an enormous challenge as the impact of new developments, new understandings of disease and the access to treatment continues to change at a pace that is difficult to stay abreast of.

The recent controversy regarding the link between industry and the guidelines that have been generated on prevention of venous thrombo-embolism typify this dilemma.   Ideally this type of review should be fundable from Government sources and therefore independently instigated and reported.   I suspect no clinician would have any issue with this.

The problem is Government support for these types of reviews is usually non-existent and, if forthcoming, is slow, bureaucratic and usually under-funded.   Industry provides a ready source of support, particularly if a product is associated with the review’s terms of reference.

There is probably little doubt that vigorous and thorough guidelines need to be developed and policed for prevention of deep venous thrombo-embolism in patients.   Whether or not the magnitude of the problem is as great as suggested by industry remains controversial, however on any given day in any hospital around Australia there is almost certainly more than one patient who should have been given prophylaxis but failed to receive it.   This will inevitably lead to problems but when they occur they are expensive, sometimes catastrophic and certainly preventable.

There is little doubt within the research literature that when studies are supported by industry, the results tend to be more favourable towards the intervention.  This is not due to any corruption but rather the nature of the relationship that seems to exist when industry funds research endeavours.  It is most likely that a similar bias also occurs when industry favours the review of guidelines although no clear data has ever been generated to support this particular contention.

The only solution is to encourage all agencies to avoid taking industry support for such work.   This, however, needs to be matched by greater efforts to acquire Government funding for these endeavours.

The solutions are not easy and not to have guidelines at all is probably worse than to have ones that may be somewhat biased by industry but the ideal should be to have ones completely divorced of industry influence.  This could be achieved by either more generous Government funding for such activities or the creation of a pool of funds managed independently and at arm’s length by some form of quasi-Government organisation as currently exists with the TGA and application is made by groups wishing to develop appropriate guidelines and recommendations for national use of drugs or devices.

Health and medical groups must make every effort to avoid linking themselves this closely with industry but, until viable alternatives exist, compromises will be required.   Until we achieve the utopian existence it is probably rational to have some guidelines rather than none and every effort should be made to divulge any conflict of interests and industry support that occurs in their generation.”