HARC eBulletin

Quarterly e-Bulletin of the Hospital Alliance for Research Collaboration

Issue 8 Welcome to our latest HARC eBulletin. In this eBulletin we highlight recent groundbreaking March reviews, research and reports that are relevant for Australian health policy deliberations. In 2009 this edition we report on new evidence for: acute geriatric units; a surgical checklist that has been shown to reduce deaths and complications that is being implemented across the NHS; Print Version processes to improve post-acute care such as discharge planning and telephone follow-up care.

On to a sombre note, the news of Dr Anna Donald’s untimely passing was received by the Australian and international research, policy and clinical communities with great sadness. In our news section below we profile her obituaries in the British Medical Journal (by Richard Smith and Muir Gray) and Morning Herald that commend her unwavering dedication to improving health services by the application of best available evidence – a goal that resonates with HARC. We pass on our condolences to Anna’s family, friends and colleagues.

Mary Haines, Health Services Research Director

News

NSW successful in latest round of NHMRC capacity building grants for population health and health services research

This eBulletin is NSW has won five of nine capacity building grants totaling $18.2million. The successful grants produced by the include “OSPREY: Building capacity for research to improve health services for mothers, HARC Office at babies and children”, which brings together a team of investigators from the University of the Sax Institute. Western Sydney, the , the University of Western Australia and the Sax Institute. Through OSPREY, nine team investigators will develop as independent researchers, substantially boosting Australia’s capacity for health services research using linked routinely collected data, and focused on a “Healthy start to life”.

For further information go to the NHMRC website by clicking here. [cited 2009 March 16]

New reports from the CEC including the Quality Systems Assessment (QSA)

Statewide Report available now

One of the key recommendations of the NSW Patient Safety and Clinical Quality Program, following the Walker report into the Camden and Campbelltown hospitals, was the development of The Quality Systems Assessment Program (QSA). The QSA statewide report: summary of findings from the Area Health Services and the Children's Hospital Westmead presents the results of the QSA self-assessment survey conducted in late 2007; the very first census in of quality and safety policies and their level of implementation. The report identifies areas of exemplary performance as well as areas for improvement and the results provide a baseline measure of the performance of AHS, Network/ Clusters, Facilities and Clinical Units in the implementation of various quality and safety programs and policies. The Quality Systems Assessment baseline survey was also undertaken by the Ambulance Service of NSW and Justice Health in February 2008.

Also available from CEC is the report Between the Flags - The Way Forward which describes the agreed way forward to implement statewide change to help keep patients safe, together with a project report on the statewide initiative on the recognition and management of the deteriorating patient - Between the Flags Interim Project Report [PDF ~1672kb].

The full reports can be accessed by clicking the relevant link above. [cited 2009 March 16]

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Two new reports available from The 45 and Up Study

The 45 and Up Study, established and managed by the Sax Institute, is the largest cohort study in the southern hemisphere with 260,000 participants aged 45 years and over. The study is now fully established as an “open resource” for internationally leading research to help us understand how we can remain healthy and independent as we age. The research team have recently produced two reports that are available to be viewed online. They are ‘Achievements to December 2008’ and ‘The 45 and Up Study Responsible Conduct of Research Report’ which summarises the structures, policies and procedures that are in place to ensure the responsible conduct of research within the 45 and Up Study.

To download these documents from the 45 and Up Study website click here.

Dr Anna Donald, a pioneer in evidence based health care, loses battle against breast cancer

The death of Anna Donald is a great loss for the field of evidence based health care. A Rhodes scholar and graduate of and Harvard, Anna published one of the first articles on the subject of evidence based medicine in 1995 while still a senior house officer; an article which has since been cited 661 times. She relentlessly pursued her conviction that a package of evidence-based interventions could make high quality care affordable for all, becoming a lecturer in health policy at University College London and founding co-editor of the journal Evidence Based Health Policy. In 1999 Anna co-founded Bazian, a company providing evidence-based consulting and analysis to support the rational assessment, configuration and commissioning of health care services. When Anna was diagnosed with metastatic breast cancer in February 2007 she continued her search for better understanding of sickness and health through her terminal illness, reporting her findings in a series of 22 blog entries called “from the other side” for the BMJ.

You can read Anna’s obituary in the BMJ and find links to her blogs here: http://www.bmj.com/cgi/content/full/338/feb04_1/b436 or read her obituary in the Sydney Morning Herald here: http://www.smh.com.au/national/obituaries/rhodes-scholar-fought-to- find-truth-20090212-85wc.html?page=-1 [cited 2009 March 16]

Review Round-up

Acute geriatric units produce a functional benefit and increase the likelihood of living at home

This systematic review and meta-analysis published in the British Medical Journal found that, for older patients (65 yrs+) with acute medical disorders, admission to acute geriatric units increased the likelihood of living at home at discharge and lowered the risk of functional decline compared with conventional hospital care. Frequency of admission to a nursing home did not differ between patients from acute geriatric and conventional care units at discharge or at three months post-discharge. There was no significant difference in case fatality, either in hospital or three months after discharge. In addition, there was a trend towards a reduced length of stay and a slight, yet significant, reduction in cost associated with treatment in acute geriatric units.

Twelve articles, involving 11 studies comprising: five randomised trials; four non- randomised trials; and two case-control studies met the inclusion criteria. The majority of studies were conducted in the US with the remaining four in Australia, Canada, Sweden and Peru.

Baztán J, Suárez-García F, López-Arrieta J, Rodríguez-Mañas L, Rodríguez-Artalejo F. Effectiveness of acute geriatric units on functional decline, living at home, and cased fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. BMJ. 2009; 338:b50. Available at: http://www.bmj.com/cgi/content/full/338/jan22_2/b50 [cited 2009 March 16]

Page 2 of 8 WHO aims to meet policy makers requirements with the launch of a new series of policy briefs

The World Health Organisation European Ministerial Conference on “Health Systems, Health and Wealth” in Tallinn, Estonia, 25-27 June 2008, was the launching ground for a new series of policy briefs. These useful briefs were developed in a joint project between the Health Evidence Network and the European Observatory on Health Systems and Policies. The series aims to meet policy makers’ requirements by presenting a rigorous review of available research evidence written in accessible language and presented in a consistent format. Nine joint policy briefs have been published bringing together key evidence, potential policy options for best practice and strategies for improving health system performance. Topics include: How can optimal skill mix be effectively implemented and why? How can the settings used to provide care to older people be balanced? How can the migration of health service professionals be managed so as to reduce any negative effects on supply? and Do lifelong learning and revalidation ensure that physicians are fit to practice?

The briefs are available at: http://www.euro.who.int/HEN/policybriefs/20080814_2 [cited 2009 March 16]

Research Round-up

Surgical safety checklist reduces deaths and complications

An estimated 234 million operations are performed globally each year. Surgical complications are common yet data suggests at least half are avoidable, findings which prompted the World Health Organisation to develop guidelines identifying multiple recommended practices to ensure patient safety worldwide.

This study, published in the New Journal of Medicine, aimed to compare the rate of complications, including death, during hospitalisation and within 30 days of operation prior to and after an intervention to implement a 19 point surgical safety checklist. This prospective study compared patient outcomes in a pre-intervention cohort and a post- intervention cohort. Data were collected between October 2007 and September 2008, from eight hospitals in eight cities around the world with diverse economic circumstances and populations that participated in the World Health Organisation’s Safe Surgery Saves Lives program. Data were collected at baseline (pre-intervention) on 3733 consecutively enrolled non-cardiac patients aged 16 or over and post-intervention on a further 3955 patients.

Postoperative complication rates fell at all sites after the introduction of the checklist, on average by 36%. The total in-hospital rate of death fell from 1.5% to 0.8%. Furthermore, overall rates of surgical-site infection and unplanned reoperation significantly declined. Introduction of the WHO Surgical Safety Checklist was associated with marked improvements in surgical outcomes in both high and low incomes sites. The effect of the intervention on outpatient complications is not known.

For more on how this study is already having an impact on NHS policy in the UK, see ‘What are People Talking About?’

Haynes AB, Weiser TG, Berry WR, Lipstiz SR, Breizat A-HS, Dellinger EP, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. NEJM 2009; 360; 491-9. The full article is available by clicking here: Free Full Text [cited 2009 March 16]

Breast cancer patients react positively to post-treatment telephone follow-up

Clinical examination, consultation and routine mammography after treatment to detect recurrent disease are the standard follow-up procedures for breast cancer patients in many countries.

This UK based study, published in the British Medical Journal, compared traditional hospital follow-up with telephone follow-up by specialist nurses in a two-centre randomised equivalence trial with 374 women at low-risk of recurrence of breast cancer. The results indicated that women who received telephone follow-up were no more anxious than those who had face to face consultations and at the end of the trial reported higher levels of satisfaction with information received than women attending hospital clinics.

Page 3 of 8 There was no difference in detection time for recurrence between the groups. The results of the study suggest telephone follow-up could reduce the load on hospital clinics without detrimental effects on patient care. The authors conclude that telephone follow up care is .. “suitable for women at low to moderate risk of recurrence and those with long travelling distances or mobility problems and decreases the load on hospital clinics”

Beaver K, Tysver-Robinson D, Campbell M, Twomey M, Williamson S, Hindley A, et al. Comparing hospital and telephone follow-up after treatment for breast cancer: randomised equivalence trial. BMJ 2009; 338; a3147. Available at: http://www.bmj.com/cgi/content/full/338/jan14_2/a3147 [cited 2009 March 16]

A package of discharge services can decrease hospital readmissions

Emergency department visits and readmissions are common after hospital discharge. Patients are often unprepared at discharge, hospital discharge summaries can lack critical information for primary care providers and discharge procedures are not standardised.

Published in the Annals of Internal Medicine, this single-centre US study tested the effects of a nurse and pharmacist led intervention aimed at minimising hospital utilisation after discharge. In a randomised, controlled trial, 749 English-speaking adults, admitted to the medical teaching service of Boston Medical Center, were randomly assigned to either the control or intervention groups. The intervention tested involved a nurse discharge advocate working with patients in the intervention group to reconcile medication and formulate a discharge plan. Following discharge, a clinical pharmacist called patients to review medication and reinforce the discharge plan.

Patients in the intervention group reported being more prepared for discharge and had a lower rate of hospital utilisation within 30 days of discharge than patients receiving usual care. The intervention was most effective for patients who had utilised hospital services in the previous six months prior to the admission being studied. The results of the study suggest that a systematic approach to hospital discharge can reduce unnecessary health service use and cost analysis demonstrated that the intervention resulted in an average reduced cost of $US412 per patient. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. Ann Intern Med 2009; 150: 178-187. For a link to the research paper please click: http://www.annals.org/cgi/content/full/150/3/178 [cited 2009 March 16]

Care coordination programs did not yield savings in patients with chronic illness

In the US, patients with multiple chronic illnesses accounted for 75% of Medicare spending in 2002. High expenditures on these patients predominantly relate to hospital admissions and readmissions and may be due to a lack of communication and coordinated care.

Between April 2002 and June 2005, 15 care coordination programs participated in randomised trials providing data on hospitalisations, costs and some quality-of-care outcomes for 18308 patients who participated voluntarily. Patients in the intervention groups were educated and monitored by nurses, mostly via telephone, to improve adherence and ability to communicate with physicians. Frequency of contact varied widely between interventions but patients were contacted on average twice per month. The results of the study, published in the Journal of the American Medical Association, found no significant difference in the number of hospitalisations in 13 of the 15 programs and none of the programs generated net savings. It should be noted, however, that the care coordination interventions varied widely, the programs had different inclusion criteria and were run in several different types of setting, including only 3 hospitals. Most of the programs enrolled high-cost patients: the average monthly Medicare expenditure of the volunteer research sample was nearly three times the national average suggesting that these data may not be generalisable. The authors conclude that despite..”underwhelming results for care coordination interventions in general”, the favourable findings for two interventions.. “suggest that the potential exists for care coordination interventions to be cost-neutral and to improve patients’ well-being”. Peikes D, Chen A, Schore J, et al. Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials. JAMA 2009; 301 (6); 603-618. Please click here for FULL TEXT [cited 2009 March 16]

Page 4 of 8 What Are People Talking About?

Have targets done more harm than good in the English NHS?

A head to head debate published in the British Medical Journal considered whether a focus on performance targets has resulted in real improvements or has ignored underlying problems important to patient care.

James Gubb, Director of the Health Unit at Civitas in London, argues that the belief that targets deliver optimal performance is misguided since the most intractable problems in health care are cultural or systematic, referring to a “lack of communication, leadership and teamwork; a lack of integration; and the lack of a meaningful, patient focused, quality framework”. He states that targets undermine clinical decision making and shift the focus away from patient’s experiences and the performance of the health care system as a whole towards crude indicators. This leads to a fractured view of performance where the true impact on patient care is concealed; for example, the introduction of targets for inpatient and outpatient waiting times led to an increase in median wait times and bed occupancy as patients were shifted to diagnostics.

Gubb J. Have targets done more harm than good in the English NHS? Yes. BMJ 2009; 338: a3130. The full argument can be read here: Have targets done more harm than good in the English NHS? Yes [cited 2009 March 16]

On the other side of the debate, Gwyn Bevan, Professor of Management Science at the London School of Economics and Political Science, argues that “detailed studies have consistently confirmed the comparative excellence of performance in England under the regime of star ratings” and that targets in the NHS are the equivalent of the bottom-line in private enterprise. She claims that whilst ‘gaming’ (ie. the practice of manipulating data) occurs, it can be tackled through audits and random checks. She suggests that “better outcomes follow from treating ill people more quickly” and that the use of targets should continue in order to maintain standards, albeit in conjunction with a focus on “continuing to improve clinical outcomes to narrow the gap with international benchmarks”.

Bevan G. Have targets done more harm than good in the English NHS? No. BMJ 2009; 338: a3129. You can read the full article at: Have targets done more harm than good in the English NHS? No [cited 2009 March 16]

World Health Organisation’s (WHO) surgical safety checklist set to become mandatory

As reported in our research round-up, use of the WHO’s 19 point surgical safety checklist significantly reduced the incidence of deaths and complications after surgery. The checklist identifies three distinct phases of an operation, each corresponding to a specific period in the normal flow of work: before anaesthesia; before skin incision; and before the patient leaves the operating room, as points at which checks should be made. Many of the checks are oral and encourage communication between the surgical team.

On 14 January, Dr Atul Gawande, surgeon at Brigham and Women's Hospital (BWH) and the Dana Farber Cancer Institute in Boston, USA and Associate Professor at the Harvard School of , one of the author’s of the study, delivered the UK National Patient Safety Agency James Reason inaugural lecture entitled ‘The checklist effect: on the fight against failure in medicine’. You can listen to him speak more about the checklist by clicking here: http://news.bbc.co.uk/1/hi/health/7825780.stm [cited 2009 March 16]

On 26 January, the UK National Patient Safety Agency issued an alert requiring all healthcare organisations in England and Wales to implement the WHO Surgical Safety Checklist (adapted for England and Wales) for every patient undergoing a surgical procedure by 1 February 2010.

The WHO Surgical Safety Checklist, an instructional video of how to use the checklist, an implementation manual and further tools and resources are available to download from the

World Health Organisation website: http://www.who.int/patientsafety/safesurgery/en/index.html [cited 2009 March 16]

Page 5 of 8 Research and innovation is the key to improvements in healthcare

On 16 February 2009, Dr Christine Bennett launched the National Health and Hospitals Reform Commission (NHHRC) Interim Report in a speech to the National Press Club. The report recommends 116 reform directions which are organised into four themes: Taking responsibility; Connecting care; Facing inequalities; and Driving quality performance. A key message of the latter theme is the need to foster continuous learning within our health system and Chapter 15 of the report calls for more health services research and greater integration of research into clinical practice. Specific reform directions relate to increased priority of health services research with greater numbers of part-time research fellowships, more infrastructure funding following direct grants, and consultation between the NHMRC and consumers, clinicians and health professionals to set priorities for collaborative research centres and supportive grants

The report can be accessed here: http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/interim-report-december- 2008 [cited 2009 March 16]

NSW hospitals perform well against government indicators

On 30 January the Productivity Commission released its Report on Government Services 2009. Chapter 10 compares public hospital services against key performance indicators. NSW hospitals performed well against equity indicators, topping the league for the percentage of emergency department patients seen within triage category timeframes, whilst reporting the lowest cost per non-admitted occasion of service, and had the smallest proportion of patients experiencing extended waits for elective surgery. Hospitals in NSW measured up well against a number of patient safety indicators, including the rate of unplanned readmissions which was lower than every state except WA, although surgical site infections were more common in NSW hospitals for the four selected procedures. Patient satisfaction statistics indicated that over 88 per cent of NSW patients rated care received as good, very good or excellent.

The full report is available at: http://www.pc.gov.au/gsp/reports/rogs/2009 [cited 2009 March 16]

Taming wide variations in Medicare spending is the key to US health reform

According to a New England Journal of Medicine Commentary from Dartmouth Atlas Project, published on 26 February 2009, “huge inefficiencies in the U.S. health care system are hamstringing the nation’s ability to expand access to care”. The analysis of Medicare spending from 1992 to 2006 in five U.S. hospital referral regions indicates an average annual increase of 3.5% after adjustment for general price inflation but statistics demonstrate considerable variation in per capita spending between regions: the annual growth rate in Miami was 5% in comparison with 2.4% in San Francisco and 1.6% in Nebraska. According to the authors, rising costs are neither unstoppable nor solely attributable to the growth in spending on advances in medical technology. Many regions have attained sustainable growth rates and patients in those regions have access to the same technology as those in high-cost regions with patients in lower cost regions often receiving better care. The researchers project that by reducing the average annual growth rate from 3.5 percent to 2.4 percent, Medicare could save $1.42 trillion by 2023, turning a large deficit into a healthy surplus. The authors call on physicians to lead the effort to reduce health care costs and bring spending under control, asserting.. “Physicians are still almost entirely responsible for determining what treatments patients receive and where they obtain their care”. They highlight the need for policies that reward low-cost slow-growth regions and encourage high growth (or high cost) regions to behave more like them. They suggest that the best strategy for slowing spending growth is to develop more organised systems of care and implement fundamental payment reform.

Fisher ES, Bynum JP, Skinner JS. Slowing the Growth of Health Care Costs – Lessons from Regional Variation. NEJM 2009; 360 (9): 849-52.

Please click here for the full article: New England Journal of Medicine paper You can read the Dartmouth Atlas Press release or a report on The Policy Implications of Variations in Medicare Spending Growth by clicking on the links. [cited 2009 March 16]

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The journey of ‘The Patient’ through the eyes of a surgeon

Published on 2 February, ‘The Patient’ by Dr Mohamed Khadra is the follow up to the controversial ‘Making the Cut’. The Professor of Surgery at University of Sydney draws on his own real-life experiences, whilst undergoing an extensive period of treatment for thyroid cancer, to relay the story of a fictional male professional, Jonathan Brewster, who discovers mid-career that he has a bladder cancer, following him through the various stages of his treatment. Dr Khadra says a prime motivation for writing ‘The Patient’ was to help patients better understand what a stay in hospital involves and encourage them to become involved in their healthcare, ask questions about their treatment and communicate with their doctors.

The Patient by Dr Mohamed Khadra. Random House. ISBN: 9781741666540

Forthcoming Events

4th HARC Forum: Public Confidence in the Hospital System: 5.00 – 7.30pm, 29 April, The Auditorium, Kolling Institute, Royal North Shore Hospital

The purpose of this forum, chaired by Professor Cliff Hughes of the NSW Clinical Excellence Commission, is to consider how we can strengthen public confidence in the hospital system through research and analysis. Dr Diane Watson, International Visiting Research Fellow at If you wish to the Sax Institute, from the University of British Columbia, will present her latest research receive future findings entitled “Research to improve public confidence and views on quality in the Canadian copies, or wish to Health System”. Using this research as a spring board, a panel of high profile health leaders, be removed from the mailing list, facilitated by Prof Hunter Watt, CEO of the Greater Metropolitan Clinical Taskforce, will discuss contact the HARC how we can build public confidence in the NSW hospital system. office via the details below. Centre for Health Economics and Research Evaluation 2009 Seminar Series Combining data linkage and evidence synthesis to inform efficient health care We rely on the provision: 28 May 2009, CHERE, UTS, Sydney information made available by our This lecture will be delivered by Associate Professor Jon Karnon from the Department of Public sources and Health at the University of Adelaide. The CHERE seminar series lectures are open to the cannot vouch for public with the purpose of engaging with leading national and international experts within the accuracy of third party Health Service Research and Health Economics. RSVP to [email protected] reports. For full details please click here: http://www.hsraanz.org/CHERE2009SeminarSeries_autumn.pdf [cited 2009 March 16]

PHAA 39th Annual Conference MAKING A DIFFERENCE Intervening to improve health outcomes: 28 - 30 September 2009, Hotel Realm, , ACT

The 2009 Public Health Association of Australia Annual Conference will focus on interventions to improve health outcomes. It aims to showcase the intervention-oriented research that is currently underway, as well as inviting cautionary tales about past and looming failures. Calls for Abstracts close on 1 April 2009.

Click on the link below to visit the website or to submit an Abstract online http://www.phaa.net.au/2009AnnualConference.php [cited 2009 March 16]

AHHA/AIHPS 2009 Congress Shaping up in Health: How does Australia become the world’s best? : 8-9 October 2009, Hotel Grand Chancellor, Hobart, Tasmania

The Australian Healthcare and Hospitals Association Congress is an opportunity to network with colleagues from across Australia and engage in a high-level discussion about healthcare policy with healthcare managers, policy writers, academic researchers and senior clinical staff. The congress will enable delegates to: learn how to create world-class services; explore what makes a high performing healthcare system; discuss the performance of Australia’s health system; and compare Australia’s outcomes nationally and internationally.

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For further details and to register interest please go to: http://sapmea.asn.au/conventions/ahha2009/index.html [cited 2009 March 16]

HSRAANZ 6th Health Services and Policy Research Conference: 25-27 November 2009, Brisbane Convention and Exhibition Centre

The Committee is still considering conference themes and potential invited speakers. The Call for Papers will be sent out in early March, with abstracts closing in June. Ideas for the conference can be emailed to the Convenor, Terri Jackson at [email protected]

www.saxinstitute.org.au www.cec.health.nsw.gov.au www.health.nsw.gov.au/gmct

HARC is an initiative from the Sax Institute and the NSW Clinical Excellence Commission

Louise Gilmour P | 02 9514 5950 F | 02 9514 5951 E | [email protected] A | PO Box 123, Broadway NSW 2007

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