NOVEMBER 2013

 How much we know about the state of safety and quality in the Australian healthcare system
 How safe are our hospitals and health services
 The purpose of the National Safety and Quality Health
Service Standards
 Using medical practice variation to improve quality

Safety
Protect the patient from harm
Quality
Appropriateness
Effectiveness

The Australian Health Care System
The Australian health system is consistently one of the top performers in OECD countries
7th longest life expectancy at birth life expectancy at birth 82 yrs
Top 5 countries for survival after heart attack & cancer
Spectacular” declines in death from CVD (Australia’s
Health)
8.9% GDP compared with OECD average 9.3%

“It may seem a strange principle to enunciate as the very first requirement in a
Hospital that it should do the sick no harm.”
Nightingale, F. First sentence of Preface to Notes on Hospitals (1859, 3rd. Ed.,1863)

• Around 12% adverse event rate
• Estimated that 50% of these events are avoidable
• Don’t know about the degree of harm
• One in 300 chance of being harmed – compared with one in one million as aircraft traveller
0.04%
0.149%
Death or serious harm
Temporary, less harm
1,782
6,816
• Medication error
• Patient falls
• HAI
• Deterioration and failure to respond
• Suicide

• Are patients/carers at the center of care?
• How many patient complaints are received? Week/month/year
• Are they resolved?
• How many SAC1 & SAC2 events?
• What is the HSMR?
• What is the infection rate?
• What is the hand washing rate?
• What is the surgical mortality?
• Results of latest climate survey?
• How are staff assessed?
• How are new technologies assessed?

• Are you getting only good news?
• Do you think that your providers are performing better than then they really are?
• Do reports contain the concerning news as well as the good news?
• What is world class performance and how do your providers compare?
• Are metrics kept simple and meaningful?
• Are these data shared with fund holders, patients and staff?
• Where does the patient/carer story fit with your Board and
Executive?

• To protect the public from harm
•
To improve the quality of health service provision

Standard 2
Partnering with
Consumers
Standard 1
Governance for Safety and
Quality in Health
Service Organisations
Standard 10
Preventing Falls and
Harm from Falls
Standard 3
Healthcare
Associated
Infections
Standard 4
Medication
Safety
Standard 9
Recognising and
Responding to Clinical
Deterioration in Acute
Health Care
Standard 8
Preventing and
Managing Pressure
Injuries
Standard 7
Blood and Blood
Products
Standard 6
Clinical
Handover
Standard 5
Patient Identification and Procedure
Matching

• Standards 1 and 2 are overarching
• Standards 3 – 10 are clinical standards, selected because they address areas where:
 The impact of poor safety or quality of care is across a large patient population
 There is a known gap between existing delivery of care and best practice
 Improvement strategies exist that are evidence based and achievable

1320 public and private health services to be assessed over 3 years
• 297 health public (57%) and private health (43%) services have undergone accreditation
Nationally
•
51% have had accreditation status confirmed
• 49% have actions that need to be addressed within 120 days

What is Medical Practice Variation? (MPV)
• MPV across & within countries widely documented
• The fact that MPV are not always linked to clinical needs or patient preference now common knowledge
• Australian Atlas of Medical Practice Variation to identify anomalies
• To stimulate change to bring practice back toward evidence
•
Decision support tools

Understanding Medical Practice Variation (MPV)
Effective Care:
• Evidence based interventions for which the benefit exceeds the harms so that most pts should receive the services
(immunisations or beta-blockers following heart attack)
Preference-sensitive care:
• Treatment options exist but carry different benefits and risks
(PSA screening vs. biopsy)
Lower-value care includes health care activities whose effectiveness has not been demonstrated
•
Plain x-ray for lower back pain, IVF treatment over 40

Unwarranted variation in care
Underuse of effective care
• e.g. screening of diabetics for retinal disease, prophylaxis for VTE, chronic heart failure management
Overuse of supply sensitive care
• e.g. overuse of acute care sector because of lack of infrastructure support for chronic disease in the community
Misuse of preference sensitive care
• e.g. Failure to accurately communicate risks & benefits of alternative treatments & failure to base the choice of treatment on the patients values & preferences

Overuse
• More health care can lead to worse outcomes
• Almost all interventions have some risks of harm &/or side effects
• Intervention “creep” to different populations where benefit unproven or < harms
• Some services become widely used but are of little proven benefit

Overuse – lower back pain
• Routine imaging in low back pain < 6/52 duration
• Low back pain lifetime incidence of 80%
• In Australia 28% of patients with low back pain have X-Rays
(US 42% of patients)
• Lumbar imaging for low back pain without indications of serious underlying conditions does not improve clinical outcomes
• Potential harms: unneeded follow up tests for incidental findings, irradiation exposure, increased risk of surgery & medical costs

Preference sensitive care
Early stage prostate cancer
• Watchful waiting: many prostate cancers never progress to affect quality of life or survival, but some do
• Radiation: shrinks or eliminates cancer in the prostate, but there are risks of side effects
• Radical prostatectomy: removes prostate cancer entirely, but there are substantial risks of incontinence & impotence
The Dartmouth Atlas of Health Care www.dartmouthatlas.org

Estimated Cost of Waste in US Health Care
Failures of care delivery - $102-154 billion
Failures of care coordination - $25-45 billion
Overtreatment - $158-226 billion
Administrative complexity - $107-389 billion
Pricing failures - $84-178 billion
Fraud & abuse - $82-272 billion
Sum of midpoint estimates: $910 billion (34% of national health expenditures)
Berwick & Hackbarth JAMA 2012

Preference sensitive care
• Studies show major gaps in people’s understanding of their treatment options
• Importance of outcomes, side effects, risks differ for individuals
• Patient preferences may be poorly understood by doctors – e.g. breast cancer
• Decisions tend to be driven by doctors & favour intervention
• Better informed patients often choose different treatments

IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America.

Preference sensitive care
Decision aids (booklets, videos, web tools)
• prepare people to participate in decisions that involve weighing potential benefits, risks & scientific uncertainties about interventions
• present sufficient information about options to help people clarify how they value benefits vs harms & what matters most
• allow informed judgments about options

Decision Aids
Cochrane systematic review
• People using evidence-based decision aids had
• improved knowledge of options
• more accurate expectations of possible benefits & harms
• choices more consistent with informed values
• greater participation in decision making
• reduced choice of major elective surgery in favour of conservative options
Stacey et al, 2011

IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America.

OECD Medical Practice Variations
2013 study – 14 countries
Key findings:
• Little variation in low-risk and high benefit procedures
(surgery after hip fracture)
• More in country variation preference sensitive care (cardiac procedures and diagnostic tests)
• Social health insurance based countries report relatively lower variation than tax-based health care systems
• Australia stands out for revascularisation and knee interventions

CABG by Medicare Local, age and sex standardised number per 100,000 population

Knee arthroscopy by Medicare Local, age and sex standardised number per 100,000 population

Hysterectomy rates by Medicare Local and agestandardised number per 1,000 female population

Age-standardised rates for prostatectomy per 100,000 males

Age-standardised rates of caesarian sections per 1000 live births

Age-standardised rates of hysterectomy per 100,000 females