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HARC eBulletin - June 2010

 

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Hospital Alliance for Research Collaboration

June 2010

 

In this edition of the HARC eBulletin, we draw to your attention studies, reports and international trends that relate to current or potential future issues facing the Australian health system.  With the launch of the first report by the independent NSW Bureau of Health Information (see story below), interest has sharply turned to optimising research and monitoring as levers to improve to our health system.

We touch on controversial topics that are being discussed locally and internationally such as: the relationship between financial incentives and performance improvement; ways to discontinue funding practices that are no longer beneficial; the selection and de-selection of performance indicators; and the association between increases in diagnostic practices in routinely collected data and the prevalence of chronic illnesses.    We also highlight studies that have tested whether initiatives such as advanced care planning and hospital accreditation result in improvements for patients and their families. 

The advent of local hospital networks and the other planned changes to our system provides us with a unique opportunity to apply research to answer the question in all of our minds - will these changes improve our health system?

 

Mary Haines
Health Services Research Director

 

To download the print version Click Here

News

Review Round-Up

 

Research Round-Up

Report Round-Up

What Are People Talking About?

Forthcoming Events

 

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News

6th HARC Forum on building health literacy with Professor Don Nutbeam - podcast available now

 

The latest HARC Forum on 12 April 2010 considered how we can improve health care delivery for people with low health literacy. It was chaired by Dr Norman Swan, a multi-award winning broadcaster and journalist and attended by over 230 professionals. Professor Don Nutbeam, an international thought leader in the field of health literacy, gave an overview of the development of the health literacy concept and presented the latest policy and research initiatives focused on improving patient health literacy. The keynote presentation was followed by two brief presentations providing perspectives from a researcher and a policy maker who work with patients with low health literacy: Dr Kirsten McCaffery, Senior Research Fellow, School of Public Health, University of Sydney; and Mr Kieran Pehm, Commissioner, NSW Health Care Complaints Commission who work with low health literacy patients.

Following the presentations, Norman Swan engaged the speakers and the audience in a lively and provoking conversation about what the evidence says we can do to improve care across the system for patients with low health literacy.

If you were unable to attend the Forum, click here to download the presentations and podcast from the Sax Institute's website

Announcing the Agency for Clinical Innovation

 

The Agency for Clinical Innovation (ACI) was established by the NSW Government in January 2010 as a board-governed statutory health corporation, in direct response to the Final Report of the Special Commission of Inquiry into Acute Care in NSW Public Hospitals by Peter Garling SC.

Professor Carol Pollock, a renal specialist and immediate past Chair of the Greater Metropolitan Clinical Taskforce (GMCT), has been appointed the inaugural Chair of the ACI Board. Building on the valuable work carried out by the GMCT and its predecessors over the past nine years, the ACI will use the expertise of its clinical networks to collaborate to develop evidence-based standards or 'models of care' for the treatment of patients. It will then support NSW Area Health Services and other public health organisations - including the soon to be established Local Hospital Networks- to implement these standards across the public health system in NSW. To realise its ambitious agenda, the ACI will work in close collaboration with the three other "pillars" of reform in NSW, the Bureau of Health Information, the Clinical Excellence Commission (CEC) and the Clinical Education and Training Institute. Common board membership with the CEC has strengthened collaboration and cooperation between the two agencies, particularly in the identification of priorities and work plans. "A critical role for the ACI will be the identification of inappropriate variation in care and research to evaluate the causes", emphasised Professor Pollock. For further details visit the ACI website

Insights into Care - new report from the Bureau of Health Information

 

The Bureau of Health Information was established following the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals (Garling inquiry) to report on quality and safety of patient care. The Bureau is an independent, board-governed organisation established by the NSW Government to be the leading source of information on the performance of the public health system in NSW. The Bureau's inaugural report, Insights into Care: Patients' Perspectives on NSW Public Hospitals, is based on analysis of the NSW Health Patient Survey 2009 of over 20,000 public health patients and looks closely at the care experiences of patients who spend a day, or one or more nights, in NSW public hospitals each year. It provides comparative information across large public hospitals about the key care experiences that matter to patients. The report provides strong evidence about what determines patients' perspectives of excellence in care which is typified by a courteous, caring culture and teamwork amongst doctors and nurses. It highlights areas where improvements are still necessary and gives insight into issues in care that could lead to significant improvements in patients' experiences.


Review Round-Up

How to improve the nursing work environment - more controlled studies

 

The nursing workforce is fundamental to the provision of safe patient care. Heavy workloads, high absenteeism and staff shortages among nurses have resulted in increased attention on nursing work environments (NWEs) in many Western countries, however little is known about the effectiveness of interventions to improve NWEs.

This systematic review, published in Implementation Science, examined which interventions have been implemented to improve the nursing work environment and their relative effectiveness.  Nursing work environment was conceptualised by 14 characteristics including, but not limited to: teamwork; leadership; workload; autonomy; clarity; and recognition. Thirty two studies were excluded due to poor study design. 11 studies, reporting on nine different interventions, met the inclusion criteria of which eight used a quasi-experimental design and three an experimental design. Five studies were conducted in hospital settings and three in nursing homes with the remainder spread across a variety of healthcare institutions. Most interventions showed mixed effects and reported significant improvements in some but not all outcome measures. Effective interventions included: 1. assignation of patients to primary nurses which made significant improvements in autonomy, workload, clarity and teamwork; 2. an educational toolbox to improve nursing staff knowledge in specific areas or help them in aspects of their daily work which improved autonomy, teamwork, leadership, professional development and participation in decision making; and 3. implementation of individualised care and clinical supervision which improved autonomy, teamwork, professional development and recognition. The authors conclude that "published studies on this topic show weaknesses in their design", "evidence to support or refute specific NWE interventions is inconclusive" and further research in this field using controlled pre/post-intervention measures is "urgently required".      

Schalk DMJ, Bijl MLP, Halfens RJG et al. Interventions aimed at improving the nursing work environment: a systematic review. Implementation Science 2010; 5: 34.  Click here to read the full review [cited 2010 June 21]

Lessons on who needs what from a national health research system

 

Health research systems, defined as 'the people, institutions, and activities whose primary purpose is to generate high quality knowledge that can be used to promote, restore, and or maintain the health status of populations', consist of a diverse and complex range of stakeholders that influence how research is defined, conducted and used.

This review, published in Health Research Policy and Systems, analysed the overlapping literature on stakeholder needs and the history of health research reforms in England to describe the needs and capabilities of the five main groups of stakeholders in health research systems, namely: policymakers (and health care managers); health professionals; patients and the general public; industry; and researchers. Key features of the policymaking systems in which these stakeholders operate in the UK are explained and phases of reform, over four decades, in the development of the English health research system to address stakeholder interests are discussed. Main lessons about the best way to build a health research system are highlighted including: the importance of comprehensively addressing the diverse needs of various interacting institutions and stakeholders; and the desirability of developing facilitating mechanisms at interfaces between the health research system and its various stakeholders. The authors conclude that "...the lessons identified, and progress made by the reforms are relevant for the design and coordination of national health research systems beyond England".

Hanney, SR, Kuruvilla S, Soper B & Mays N. Who needs what from a national health research system: lessons from reforms to the English Department of Health's R&D system. Health Research policy and Systems 2010; 8: 11. Click here to read the full review. [cited 2010 June 21]


 

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Research Round-Up

Removing financial incentives results in decline in performance levels


Financial incentives are attached to clinical quality indicators in many healthcare systems worldwide and have been shown to lead to improvements in clinical quality. In the UK the Quality and Outcomes Framework, introduced into primary care in 2004, includes the clinical care of people with chronic diseases. It costs the UK economy about £1bn per year. Eight clinical indicators will be removed from the framework in April 2011 but no data regarding the impact of removing incentives for doctors on clinical quality are available from the UK.

The objective of this longitudinal study of more than 2.5million participants from 1997-2007, published in the British Medical Journal, was to evaluate the effect of financial incentives on four clinical quality indicators at 35 medical facilities of Kaiser Permanente Northern California common to pay for performance plans in the UK, namely: yearly assessment of patient level glycaemic control; screening for diabetic retinopathy, control of hypertension; and screening for cervical cancer. Following the introduction of financial incentives in 2001, levels of achievement for glycaemic control increased from initial levels of 44.2% in 1999 to 69.8% in 2007. A similar pattern was reported for control of hypertension although data were only available from 2002 (58.3%) to 2007 (78.2%). Financial incentives were removed during the study period for the remaining two indicators. Screening for diabetic retinopathy was incentivised for 5 consecutive years from 1999 - 2003 resulting in a rise in the proportion of screening from 84.9% to 88.1%. Following removal of incentives in 2004 the rate fell yearly to 80.5% in 2007. Regression analyses revealed that screening rates for cervical cancer increased during the initial two years when financial incentives were attached then fell by about 2% per year between 2001 and 2005 when incentives were removed. When incentives were reintroduced in 2006-7 screening rates increased again. The authors conclude that "if removal of financial incentives means that performance levels, and therefore potentially patient care, decline, this may have direct practical implications for policy makers, clinicians and patients".

Lester H, Schmittdiel J, Selby J et al. The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators. BMJ 2010; 340: c1898. Please click here for the full article [cited 2010 June 21]

See What Are People Talking About below for a linked analysis piece .


Hospital accreditation does not increase cardiology inpatient satisfaction 


Patient satisfaction is a widely accepted benchmark of quality of care in healthcare settings. Hospitals in many countries are undergoing either voluntary or mandatory accreditation which focuses on a number of factors such as staffing levels, infrastructure and discharge information that are believed to positively influence quality of care and patient satisfaction.

This study, published in BMC Health Services Research, collected validated questionnaire data from 3,037 consecutive patients discharged from 25 cardiology units in Germany in 2007 to determine whether there was a relationship between patient satisfaction and accreditation status using recommendation rate as a proxy measure of patient satisfaction. 1,835 patients were treated in one of the fifteen out of 25 cardiology units accredited in line with nationally accepted standards. The remaining 1,202 patients were treated in non-accredited units. No significant differences were found between accredited and non-accredited hospitals for hospital (length of stay, staffing level) or patient (gender, age, proportion of foreign patients) characteristics. Notably, the recommendation rate for accredited hospitals was not significantly different to that for non-accredited hospitals nor was there any difference between specific factors of patient satisfaction such as patient perceptions of physician and nursing staff or admission or discharge procedures. The authors conclude that the results of this study "indicate that hospital accreditation process does not correlate with patient satisfaction and service quality as perceived by the patient, therefore providing evidence that an accreditation is not linked to improved patient satisfaction".

Sack C, Lütkes P, Günther W et al. Challenging the holy grail of hospital accreditation: A cross-sectional study of inpatient satisfaction in the field of cardiology. BMC Health Services Research 2010; 10: 120. Please click here for the full article [cited 2010 June 21]

 

Advanced care planning improves end of life and improves patient and family satisfaction


It is widely recognised that end of life care is inadequate and there is often a lack of knowledge of patients' wishes about their medical treatment when they lose the capacity to make decisions. Improving end of life care through advance care planning, which empowers patients to have input into their current and future treatment, is supported by legislation in Australia, the UK and the US.

This Australian prospective randomised controlled trial of medical inpatients in a university hospital in Melbourne investigated the impact of advance care planning on end of life care in 309 legally competent elderly patients aged 80 or over. Patients were randomly assigned to the intervention or usual care. Of the 154 patients randomised to the intervention, 125 (81%) received formalised advanced care planning using the Respecting Patient Choices model whereby patients and their families were assisted to reflect on the patients' goals, values and beliefs and discuss and document their future choices about end of life health care in an advance care plan, with the assistance of trained non-medical facilitators and treating doctors.

The results, published in the British Medical Journal, demonstrate that advance care planning had a significant positive effect on primary and secondary outcome measures: six months after randomisation, end of life wishes were known and respected in 25 of 29 (86%) patients who died in the intervention group compared with only 8 of 27 (30%) in the control group; patients and family members in the intervention group were more likely to be very satisfied with care received and perceived quality of death; furthermore, family members of patients who had died in the intervention group had fewer symptoms of post-traumatic stress, depression and anxiety.  The authors conclude that advance care planning "improves end of life care and patient and family satisfaction and reduces stress, anxiety and depression in surviving relatives" .  

Detering KM, Hancock AD Reade MC & Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 2010; 340: c1345.  Please click here for the full article [cited 2010 June 21]


Risk adjustment biased by regional variations in diagnostic practices


Current methods of risk-adjustment used in comparative-effectiveness studies rely on diagnoses recorded in clinical and administrative records but there are well-documented differences in diagnostic intensity across hospitals in the US. Among all Medicare beneficiaries, residence in regions that have a higher intensity of services corresponds with higher reported prevalence of common chronic illnesses. This raises the question of whether these higher rates reflect the true underlying prevalence of disease in the population or are the result of over servicing of the population.

Published in The New England Journal of Medicine, this study measured trends in diagnostic practices using Medicare claims data from 1999-2006. 255,264 Medicare beneficiaries, aged 65 or over, who changed their place of residence between 2001 and 2003, were followed for 2 years before and 3 years after a move from one region to another. Measures included both diagnostic practices (rates of diagnostic testing, imaging and numbers of major chronic conditions) and Hierarchical Condition Categories (HCC) risk scores.  306 Hospital Referral Regions were grouped into five quintiles according to local intensity of practice. 

The results indicate that, while the number of diagnoses and HCC measures increased universally as the cohort aged, a move to a region with a higher intensity of practice was associated with greater increases in diagnostic testing, the number of recorded chronic conditions and HCC scores. For example, a move from the lowest quintile to a higher quintile was associated with a 100.8% increase in the average number of diagnoses compared with a 61.7% increase for those who moved to regions in the lowest quintile. After 3 years there was no evidence of a survival benefit among those who moved to higher-intensity regions compared with those who moved to lower lower-intensity regions. The authors conclude that "the use of clinical or claims based diagnoses in risk adjustment may introduce important biases in comparative-effectiveness studies, public reporting and payment reform".

Song Y, Skinner J, Bynum J et al. Regional Variations in Diagnostic Practices. N Engl J Med 2010; 10: 1056. Click here for full text [cited 2010 June 21]
   

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Report Round-Up

Effective ways to realise policy reforms in health systems


The new OECD Health Working paper (No. 51) Effective Ways to Realise Policy Reforms in Health Systems contributes to a wider OECD project called Making Reform Happen which considers the factors underpinning successful implementation of reforms. It is based on evidence from the countries which have seen their health systems reviewed by the OECD in recent years, and on a selected review of the literature. The report considers four issues that impact on health reform efforts: i) the existence of appropriate institutions to support reform from decision to implementation; ii) the impact on, and reactions of, those affected by the reforms; iii) reform agendas, timing and interactions across different policy areas; and iv) the role of evidence and international organisations to sustain reforms. A number of stages of reform that need to be implemented before a reform can be successful are outlined.

The full report can be read here           

    
National Pain Strategy - pain management for all Australians


This report, developed by the National Pain Summit Initiative, highlights 12 priority objectives identified and supported by 200 delegates at the National Pain Summit held in March 2010 to improve the assessment and treatment of all forms of pain including acute, chronic and cancer-related pain. The strategy provides a background on the nature and burden of pain, identifies where delivery of care is not working and reviews the existing evidence for a range of treatments for different pain conditions at different stages. A Strategic Action Plan is set out which includes six goals to achieve improved quality of life for people with pain and their families, and to minimise the burden of pain on individuals and the community. 

The full strategy can be viewed here 


Health system expenditure on disease and injury in Australia, 2004-05

 

The third report in a series on disease expenditure from the Australian Institute of Health and Welfare provides a systematic analysis of health system expenditures associated with specific disease and injury groups in Australia, according to age and sex, and for the seven National Health Priority Areas, and analyses changes in selected areas of health expenditure between 2000-01 and 2004-05. The report identifies seven disease groups that accounted for 70%, $52.7billion, of allocated health expenditure in Australia in 2004-05, the top three being: cardiovascular disease ($5.9bn); oral health ($5.3bn); and mental disorders ($4.1bn). Disease expenditure estimates are broken down into 8 areas including admitted patient hospital services, out-of-hospital medical services and prescription pharmaceuticals. Analyses of changes from 2000-2001 to 2004-05, reveal a growth in inflation-adjusted expenditure of 20% ($7.2bn), a 4.6% increase per year.                      

The full report can be read here

 

Blueprint for the dissemination of evidence-based practices in health care


This report from the Commonwealth Fund, proposes a blueprint of eight effective strategies for improving the dissemination of evidence-based best practices based on the experiences of four successful national quality campaigns.  Examples of the strategies include: highlighting the evidence base and relative simplicity of recommended practices; aligning campaigns with the strategic goals of adopting organizations; increasing recruitment by integrating opinion leaders into the enrolment process; developing practical implementation tools and guides for key stakeholder groups; creating networks to foster learning opportunities; and incorporating monitoring and evaluation of milestones and goals. The report also highlights the importance of contextual factors, including the nature of the innovation itself, external environmental incentives, and features of adopting organizations on the impact of quality campaigns. 

The full report is available here


Revision of professional roles and quality improvement: a review of the evidence 


This report from the Health Foundation considers the impact of professional role revision on quality of care and cost-effectiveness. It focuses on two types of changes to professional roles: substitution of a doctor with a non-medical clinician; and supplementation of existing service provision within a health delivery system by adding a non-medical clinician. The revision of tasks performed by doctors with them instead being performed by: advanced practice nurses such as nurse practitioners, specialist nurses, clinical nurses and practice nurses; physician assistants; pharmacists; and allied healthcare professionals are considered. The report identifies factors that are most likely to lead to successful implementation such as: clear definition of functions, levels of autonomy, lines of accountability, experience and qualifications; development of training programmes; and systems for the accreditation and licensing of professionals working in revised roles. A review of existing evidence found no detrimental effect of revising or extending the roles of non-medical professionals on the quality of patient care.

The full report can be read here  


 

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What are people talking about? 

When has a performance indicator run its course?

 

With the announcement that eight quality indicators will be removed from the UK Quality and Outcomes Framework next year, this analysis piece in the British Medical Journal explains why they were chosen and suggests a rationale for how to select indictors for replacement based on statistical measures. The authors propose that performance of an indicator should be assessed in a number of ways including: averages, trends and variation in achievement rates; and averages, trends and variations in exception reporting rates. Trends in performance can help identify indicators that have reached their limits of achievement - where there is consistently high performance or a plateau in the growth curve there is an argument for replacing the indicator. This is the case for blood pressure monitoring in diabetic patients, one of the eight indicators due to be removed, which has extremely high and stable performance in both achievement and exception reporting rates with low inter-practice variation. Conversely, where there is widespread variation in achievement rates then many providers could substantially improve performance and the indicator should remain. The authors note that other factors such as policy considerations, the validity of the indicator and the consequences of replacement will also influence the decision to remove an indicator.    

The full analysis can be read here

To read the related study on the impact of removing financial incentives from quality indicators click here

 

NICE cost-cutting guidance on disinvestment could help save millions

 

In response to calls in the 2010 budget for the UK Department of Health to make savings of £4.35bn, the National Institute for Health and Clinical Excellence (NICE) has identified 19 sets of recommendations that could help save millions of pounds. The list covers all clinical guidelines from January 2005 as well as technology appraisals from January 2006 that deliver a net saving without investment. A range of cost cutting tools have been developed in conjunction with the list to help implement the guidance and assess the impact on local budgets. According to NICE, the guidance can also help primary care trusts and other public health organisations to achieve the goals and priorities set out in the NHS operating framework. Examples of estimated savings include £446,627 per 100,000 patients treated in line with guidance to control hypertension thereby reducing the occurrence of cardiovascular events, a total saving of over £200m. Other recommendations include changes in the treatment of patients with a variety of conditions and diseases such as breast cancer and ischaemic heart disease.

The full set of cost-saving guidelines and tools can be found here    

 

A call for routine clinical audit to measure quality of care

 

In response to growing criticisms of the hospital standardised mortality ratio (HSMR) as a measure of quality of care as well as insinuations that hospitals are 'gaming' the system by recording more comorbidities against each patient to make themselves look better, this Editor's Choice from the British Medical Journal, questions how we should measure quality of care. A return to clinical audit is the answer proposed by Nick Black, in an accompanying editorial, who believes the "quality of care provided by hospitals needs to be assessed objectively not only to stimulate clinicians and managers to make improvements but also to ensure public accountability, to enable patients to make informed choices, and to facilitate informed commissioning". This suggestion is supported by critics of the HSMR who believe "audit of adherence to the tenets of evidence based safe care"  has the advantage since it reveals where problems might lie and suggests what actions should follow, using a bottom-up approach where clinical teams have the tools and capacity to monitor and respond to their own errors.     

Click for the full article, linked editorial and analysis 


More consistency needed in Australian clinical practice guidelines

 

The authors of a recent study, published in the Medical Journal of Australia, which identified 313 clinical practice guidelines produced or reviewed between 2003 and 2007 for use in Australia at a national or state level argue that a more coordinated approach to identifying national priorities for developing and updating clinical practice guidelines is needed to produce better returns on investment. Assessment of the characteristics of the guidelines revealed more than 80 different producers - just over half were produced or funded by Federal or state government agencies but funding was not necessarily directed at areas with a large burden of disease. Less than a third of the guidelines were evidence-based and of these a number had not been updated in line with specified review dates. The authors also note the need for greater transparency in documenting the guideline development process including more consistent declaration of competing interests.

The full article can be read here

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Forthcoming Events

Menzies Centre for Health Policy: Innovations in Care - Local Hospital Networks and the Health Reform Agenda: 5.30 pm, July 6 2010, University of Sydney

 

This the second in the Policy Innovations 2010 seminar series examining how the National Health and Hospitals Network Agreement will support the Health Reform Agenda. A presentation entitled "How well will the new hospital networks and primary care organisations suit us? By Professor Stephen Leeder, Director, Menzies Centre for Health Policy will be followed by a panel discussion moderated by Dr Barry Catchlove, Fellow of Senate, University of Sydney.

For further details email mchp@sydney.edu.au

NSW & ACT Cancer Epidemiology Network Workshop: 1.30 - 6.00pm, July 14 2010, Easter Avenue Lecture Theatre, University of Sydney

 

This half-day workshop incorporating talks from guest speakers and presentations from research students. A light lunch will be followed by a presentation from Professor Bruce Armstrong describing his recent experience in doing methodological research projects nested within, or done in parallel with, ongoing case-control studies of cancer. The projects address questions like: What is the best way to select and recruit a control group? How can we improve participation rates? How accurate is recall of past behaviour? Is recall different between cases and controls? The workshop will be followed by a public lecture at 6:30pm to celebrate the opening of the Sydney Cancer Conference 2010.

Email merilyn.heuschkel@sydney.edu.au to register for the public lecture by Thursday 1 July 2010. Research students interested in presenting their research at the workshop should email christine.madronio@sydney.edu.au. Further details of the Sydney Cancer Conference can be found here .

Menzies Centre for Health Policy: Emerging Health Policy Research Conference: August 11 2010, University of Sydney

 

The 5th annual Emerging Health Policy Research Conference will showcase the work in progress of current doctoral and early career research workers, as well as those new to the field of health policy research. Participation will provide an opportunity to: discuss health policy responses to current local, national and global health challenges; present 'in progress' health policy research to a wide audience of students, academics and practitioners; and discuss new ideas and identify opportunities for collaboration across disciplinary boundaries.

For further details click here

First IASP International Pain Summit: Sept 3 2010, Montreal, Canada

 

The International Pain Summit in Montréal will be the first global meeting about the crucial aspects of pain management, with a focus on advocacy and assistance for all countries to develop national pain strategies.
To view more information about the International Pain Summit and to register, visit the IASP website

AsPac 2010 International Mental Health Conference; Hope - Recovery - Future: Nov 17 2010 - Nov 19 2010, Hobart, Tasmania

The purpose of this year's theme Hope - Recovery - Future is to explore the range of issues that impinge on the psychosocial well being of everyone. A wide range of issues will be explored in order to encourage effective policy direction designed to enhance and improve the well-being of all concerned, both state-wide and nationally. This entails recognition of the vital roles played by both an individual's sound mental and physical health.

For further details click here

 

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