Russell writes:

“A study released in the US this month is sure to provoke a range of reactions from health care professionals in Australia. It found that walk-in medical clinics runs by retailers provide care for routine illnesses that is as good as, and costs less than, similar care offered in doctors’ offices, hospital emergency rooms and urgent care centres.

Retail medical clinics are walk-up medical providers typically located in drug stores and other retail chain stores such as Target and Wal-Mart rather than in medical facilities. Care most often is provided by nurse practitioners rather than by doctors.

The study compared the care provided in different settings for patients with middle ear infections, sore throats and urinary tract infections. Researchers found no difference in the quality offered to patients visiting retail clinics, physician offices and urgent care centers, but retail clinics did slightly better than hospital emergency departments.

The quality of medical care was judged using 14 indicators of quality and whether patients received seven preventive care services during the initial visit or over the subsequent three months.

Quality scores for retail clinics were equal to or higher than those in other care settings. The study found that the costs of treating the acute illnesses at retail clinics were 30 percent to 40 percent lower than in physician offices or urgent care centers and 80 percent lower than in emergency departments. The differences were primarily caused by lower payments for professional services and lower rates of laboratory testing.

A second related study found that more enterprises are beginning to operate retail medical clinics, with an increasing number of hospital chains and physician groups becoming involved.

Retailer Wal-Mart has partnered with local hospitals to co-brand clinics in its stores, and MinuteClinic and the Cleveland Clinic recently announced a partnership to run nine clinics together and to integrate electronic medical records.

These studies were published in the Annals of Internal Medicine, 1 September 2009. Abstracts are available here.

• Dr Lesley Russell is Menzies Foundation Fellow at the Menzies Centre for Health Policy at the University of Sydney and the Australian National 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.

Hello Melissa

While acknowledging that the consequences of actual harm arising from an opinion piece in a newspaper compared to the harm that can occur in a healthcare setting are vastly different, I admire your attempt to draw a parallel between the two situations and appreciate the opportunity to povide advice to the media!

Perhaps the media can learn a lot from the health system if it does choose to analyse its own adverse events. Health offers adverse reporting systems, root cause analysis, open disclosure, handover protocols and systems to respond to the situation of the acutely deteriorating patient. The health system has long acknowledged that “to err is human” and acknowledged that it must work to prevent harm arising fom error, and, where error does occur, to be open about it and to learn from the consequences.

Health has a well established system of reporting of adverse events; in South Australia, for example, health care workers can phone a hot line 24 hours a day, seven days a week and provide information on any actual or potential adverse event, confidentially if they wish. They do not need to complete any paper work, so user friendly is the system.

The Australian Council for Safety and Quality in Health Care brought the process of Root Cause Analysis to the categorisation and analysis of adverse events. Eight of these events, the “Sentinel Events”, are provided by each jurisdiction and are published annually, to the delight of the newspaper sub editors whose most frequent contribution to serious analysis of these complex events is to headline them as simple ‘blunders” and “bungles”.

In response to your own scenario, the potential for such events unfolding is why we have national projects on clinical handover, so that accurate information about patients can be passed on between settings of care and shifts of care.

It is why the Commission is developing national initiatives to recognise patients who are acutely deteriorating while in hospital care and to rescue them when they are deteriorating. It is why Health Ministers have declared that all health care organisations will work to implement the Open Disclosure standard, developed by our predecessor, the Council.

I’m sure there would be any number of health care personnel in Australia happy to help the media sort out its processes of adverse event analysis and reporting at any time!

Regards

Chris Baggoley

Reading about the many factors and circumstances – both systemic and individual – that contributed to the error – I was again reminded of how the media and health industries have so much in common, at least when it comes to making mistakes.

I’ve taken the liberty of borrowing her article, and making a few minor tweaks, to test my theory….

How does The Hospital harm patients “in error”? Here’s how

Picture The Hospital at the end of the silly season. To be clear, picture it on the afternoon and evening of Friday 16 January, the day on which a patient suffered serious harm that, in hindsight, should have been entirely preventable.

The account below has been stitched together from half a dozen sources observing the action, although several of those who know most are not talking.

It’s not putting it too strongly to say they are devastated by the events of the last week.

This is, as hospital errors so often are, a story of cock-up rather than negligence or malevolence.

Here is the scene. Key people are on holiday, including the staff specialist, who has extended her leave by another week, leaving a hole to be filled. Other senior staff are also on holiday.

The staff are in any case depleted and demoralised — hoping for the best, yet reading daily about the demise of the hospital system. Just two days before, there had been another major report highlighting the system’s shortcomings. There are many vacant positions that cannot be filled.

In the quest for greater efficiencies, staff have been reorganised so that many are working in areas outside their expertise and beyond their levels of experience.

On Friday there was not time to think about the grim prospects for hospitals, or even to winge, because for the silly season it was a busy day – the combination of road crashes, a spike in domestic violence and a heat wave – and everyone was flat out.

Nobody in particular was thinking about the time bomb of patient X. The evening wore on; senior staff knew that X was deteriorating, but he did not get their close attention. It was only after some of them had left behind the pressures of the day, that key phrases came back to them, and alarm bells rang, that perhaps there had been several lapses in his care. The checks and balances meant to ensure quality care were, for a variety of reasons, not in place.

Very late that night – as X slipped beyond any chance of recovery – a senior doctor was alerted to the fact that there might have been a serious adverse event.

When news of the stuff-up subsequently hit the airwaves, the brown stuff hit the fan. The hospital manager returned from holiday to find the head honchos from the Minister’s and Department’s office filling his inbox, his message queue and by Monday afternoon, his office. On Tuesday the hospital published its apology.

What can be learned from all this? Evenings like last Friday occur in hospitals all the time. There is a reason one of the leading textbooks on hospital management has the title The Daily Miracle – as in it’s a miracle there aren’t more stuff ups.

So these are the events that The Hospital tried to sum up by saying the patient was harmed “in error”.

You could say nobody was to blame.

You could say everyone was to blame.

…. And thus concludes my (slightly) modified version of the Simons article.

An interesting question remains: which industry does the best job of declaring and learning from its mistakes?

The health care industry is far from perfect in this respect, but my guess would be that it trumps the media industry on this count.  I’m not aware, for example, of there being “open disclosure workshops” for media managers and journalists, as there are in some hospitals.

Which is quite ironic, given how quick we in the media are to bag the health system for its failings.