Patient Safety - Australian landmark research project reveals shortfalls
Australians receive “appropriate” health care in only 57 per cent of consultations, according the first ever national snapshot of the quality of clinical care in Australia, says the Australian Patient Safety Foundation.
A landmark CareTrack study, published recently in Medical Journal of Australia (MJA), found that although there were pockets of excellence in Australian health care delivery there were also shortfalls in treatment for some common conditions and disparities in the standards of care provided by different medical practices.
Research teams from the Australian Patient Safety Foundation, the University of South Australia and the University of NSW spent two years tracking levels of “appropriate care” -- that is care in line with best practice based on the latest medical evidence – in a representative sample of the Australian population.
For some conditions, such as coronary artery disease, patients received very high levels of appropriate care but there was poor compliance with appropriate care standards in some others areas, such as responding to very high blood pressure, administering prophylactic antibiotics at the correct time before surgery, and treating sinusitis.
Discrepancies between healthcare providers were also significant, with some offering appropriate care in 86 per cent of encounters and some in only 32 per cent of encounters.
The study focused on 22 common conditions responsible for over 40 per cent of the total national disease burden.
“Seventeen years after the landmark Quality in Australian Health Care Study, our research provides an opportunity to establish a healthcare baseline from which to move forward, and has identified some gaps in care which should be addressed,” says lead researcher at the University of South Australia and President of the Australian Patient Safety Foundation, Professor Bill Runciman.
This is the second study of its kind to be conducted in the world. The first, conducted in the United States 10 years ago, found 55 per cent of US healthcare encounters provided appropriate care.
CareTrack Australia assessed the appropriateness of the healthcare received by 1,150 Australians in 2009 and 2010 in 35,573 healthcare encounters for conditions ranging from coronary heart disease and low back pain, through to stroke, asthma and depression.
Among the study’s key findings were:-
- Appropriate care was provided in 57 per cent of healthcare encounters in Australia
- Nearly 90% of patients with sinusitis were prescribed antibiotics, care known to be ineffective
- 18% of patients with asthma had a documented action plan for when they had an attack.
- Less than 30% of patients over 50 had a documented bowel cancer screening test.
- 73% of 50 to 69 year old women had a mammogram every two years
- Almost 90% of people over 18 years old had two yearly blood pressure checks
With health budgets under growing pressure from the ageing population and costly chronic diseases, the study provides a road map for more efficient and cost-effective care delivery.
“Healthcare is likely to become unaffordable unless more appropriate care is provided,” said one of the study’s Chief Investigators, Professor Jeffrey Braithwaite of the University of NSW.
“To plan for a sustainable healthcare system into the future, it’s important to maximise the rate at which patients receive appropriate care so we can address the gaps in care that have been identified.” The study identified a number of barriers to providing appropriate care into the future. Plans to overcome these limitations include a Wikipedia-style collaborative process to develop national clinical standards and tools to guide treatment and to document whether care is appropriate.
The proposed up to date, simple standards can be embedded as tools in both patient and healthcare provider held medical records, paving the way for automatic electronic monitoring and feedback.
The $2 million CareTrack research project was undertaken as one part of an $8.4 million National Health and Medical Research Council program grant, Patient safety; enabling and supporting change for a safer more effective health system, awarded in 2009.
“Healthcare is likely to become unaffordable unless more appropriate care is provided,” said one of the study’s Chief Investigators, Professor Jeffrey Braithwaite of the University of NSW.
CareTrack Australia is part of a National Health & Medical Research Council (NHMRC) funded program that is examining the appropriateness of the care provided in Australia for 22 common conditions. It found wide discrepancies between the level of appropriate care provided among the study participants.
There has been some controversy surrounding the study and its methodology, yet this should be kept in perspective and any project that aims to improve patient safety should be welcomed.
This is important research as it outlines the urgent need for a much better understanding of what constitutes appropriate care for patients. It will provide a road map for future development of clinical standards.
Varying standards of health care
Medical professionals have a difficult job trying to keep up-to-date with best practice and what is considered acceptable care, and unfortunately a failure to do this is one of the reasons why too many Australians receive health care that is well below expected standards.
The CareTrack study has rightly highlighted the need for agreement at a national level about what comprises best practice in key areas, particularly the need for one set of accepted standards and routine monitoring of health care. Maurice Blackburn lawyers in the medical field say they often see poor outcomes, and hope that this study will lead to much better care for patients.
Study to help poor outcomes in medical law
Medical law issues occur when the treatment provided by a health service provider (such as a hospital, doctor, dentist, pharmacist, etc) falls below an acceptable standard.
Maurice Blackburn lawyers say a poor outcome for a patient will not always mean there has been negligent care. A set of agreed standards would also make it easier to prove or disprove allegations of medical negligence made by health care users.
They say the CareTrack study also highlights that more thorough auditing of doctors is required to ensure they adhere to the latest best practice standards in providing care.
Objective: To determine the percentage of health care encounters at which a sample of adult Australians received appropriate care (ie, care in line with evidence-based or consensus-based guidelines).
Design, setting and participants: Computer-assisted telephone interviews and retrospective review of the medical records (for 2009–2010) of a sample of at least 1000 Australian adults to measure compliance with 522 expert consensus indicators representing appropriate care for 22 common conditions.
Participants were selected from households in areas of South Australia and New South Wales chosen to be representative of the socioeconomic profile of Australians. Health care encounters occurred in health care practices and hospitals with general practitioners, specialists, physiotherapists, chiropractors, psychologists and counsellors.
Main outcome measure: Percentage of health care encounters at which the sample received appropriate care.
Results: From 15 292 households contacted by telephone, 7649 individuals agreed to participate, 3567 consented, 2638 proved eligible, and 1154 were included after gaining the consent of their health care providers. The adult Australians in this sample received appropriate care at 57% (95% CI, 54%– 60%) of 35 573 eligible health care encounters. Compliance with indicators of appropriate care at condition level ranged from 13% (95% CI, 1%–43%) for alcohol dependence to 90% (95% CI, 85%–93%) for coronary artery disease. For health care providers with more than 300 eligible encounters each, overall compliance ranged from 32% to 86%.
Conclusions: Although there were pockets of excellence and some aspects of care were well managed across health care providers, the consistent delivery of appropriate care needs improvement, and gaps in care should be addressed. There is a need for national agreement on clinical standards and better structuring of medical records to facilitate the delivery of more appropriate care.
Patient Safety: enabling and supporting change for a safer and more effective health system
University of NSW
Professor Braithwaite and his co-investigators were awarded an National Health and Medical Research Council (NHMRC) research grant totalling $8.4 million. The NHMRC Program Grant [Chief Investigators, Professor Jeffrey Braithwaite, Director Centre for Clinical Governance Research in Health (CCGR); Professor Johanna Westbrook, Director Centre for Health Systems and Safety Research; Professor Enrico Coiera, Director Centre for Health Informatics (CHI), Professor William Runciman, Director Australian Patient Safety Foundation (APSF) and Professor Ric Day, Director of Clinical Pharmacology & Toxicology, St Vincent’s Hospital, Sydney] is examining, across Australia, various facts of patient safety. The grant is valued at $8.4 million.
Australian Institute of Health Innovation’s Professor Braithwaite explains the project aims and findings:
Project Main Description
Internationally, patient safety is a growing concern. Patient harm occurs in 10% of hospital admissions. A million adverse events occur in general practice each year in Australia. Overseas data reports that patients receive recommended care only 50% of the time. We will significantly advance this work by investigating how and why this occurs, with a focus on the roles of teamwork, safe medication use and the application of information technology to support improved decision-making.
The program administered by the Australian Institute of Health Innovation, the University of New South Wales, commenced in January 2009 for five years providing exciting career and higher degree opportunities.
Despite widespread recognition of the need for reliable measures of the state of health care, we still have a poor understanding of what goes wrong in health care, and, particularly, how and why things go wrong. There is an urgent need to develop genuinely safe health services based on sound theoretical foundations, grounded in accurate, relevant measurements of the health system, and an understanding of behavioural and practice change, using technology shaped by an understanding of clinical work.
The Chief Investigators are internationally recognised for their leadership in the field of patient safety. They bring together various interrelated areas of expertise in health informatics, medicine, medication errors and the cultural determinants of health care problems.
The scope of the project includes collaboration with national and international partners.
Some 15 research staff and ten higher degree students are engaged in the grant, with multiple other colleagues and partners involved. A brief description of the aims of each of the four cross-linked sub-program is given below:
Which plans are being used to treat patients, and why are they chosen?
Aim 1: To extend our capabilities to measure the adoption of clinical best practice and to determine for the first time the extent to which Australians receive care consistent with the standards suggested by evidence- and consensus-based best clinical practice.
Aim 2: To determine the reasons that underlie provision of care that deviates from best practice.
Stage 1: A random population survey of around 6600 to ask about use of health services and consent to access medical records.
Stage 2: Review of consenting patient records.
Stage 3: Telephone interviews with around 2000 practitioners involved in the treatment of people identified in stage 1.
Stage 4: A subset around 3000 participants from stage 1 being re-interviewed.
What system problems perpetuate flawed plans and failures of their execution?
Aims: To identify and measure the impact of clinicians’ work and communication patterns, social networks, and team and organisational factors, on safe plan execution.
Which information technology interventions are most likely to enhance the selection of the right plan, and its effective execution?
Aim 1: To study the determinants of safe and effective clinical decision-making mediated by decision support technologies.
Aim 2: To determine the design parameters for safe and effective decision support system use in real world clinical settings.
Can a theoretical synthesis of safety research build a safety model that predicts the dynamic and complex interactions of health service performance?
Aim 1: To use information from the literature and our research programs to develop and iteratively refine a computational model of each of the layers of health care and of the interactions between them.
Aim 2: To use modelling and simulation to help identify practices and organisational components that fail tests of safety and quality, and to use the model as a predicative tool to guide research and policy about the safety and quality remedies most likely to succeed in given contexts.
Some lessons learnt
The lessons learnt are in the diverse patient safety domains of medication safety, appropriateness, e-health, incident classification, uptake of evidence, and systems change. The twelve studies outlined below are a small sample of over 150 peer-reviewed papers that have been published.
We demonstrated empirically for the first time that interruptions to nurses during medication administration are associated with a significant increase in both the incidence and severity of medication errors.
We published the first large-scale Australian study demonstrating the effectiveness of electronic prescribing systems in two hospitals to reduce prescribing errors. Overall, there was a significant 60% reduction in total prescribing error rate and a significant decrease in the proportion of serious prescribing errors. We examined two commercial e-prescribing systems and found both introduced new ‘system-related’ errors which constituted 35% of all post-intervention prescribing errors. The paper has received wide national and international media attention.
We used a highly innovative observational method to understand how decision support influenced prescribing decisions during ward rounds. We showed that there was a mis-match between the decision-makers (senior clinicians on the ward rounds) and those doctors using the electronic prescribing systems (junior doctors). As such the decision-makers did not have access to the electronic alerts, and junior doctors ignored decision alerts in this situation.
This is one of the first studies to identify the context in which decisions and electronic information systems are used may greatly influence the impact of decision support.
We have undertaken the first population-based study (“CareTrack”) on the appropriateness of health care received by Australians. The study is using a retrospective medical record review on over 1,000 patient records with 22 common conditions and 522 indicators. The indicators have been developed from national and international guidelines.
Major nations are spending tens of billions of dollars on different approaches to the design and implementation of eHealth, with limited success. We showed that top-down centralized (UK) and bottom-up laissez-faire (US) approaches to structuring national IT programs were failing, and proposed a new ‘middle out’ approach to co-ordination. Within six months, the final report of Australia’s National Health and Hospital Reform Commission specifically recommended Australia’s eHealth program be governed using this middle-out model; similar recommendations have since been made in England and Canada.
Although incident reporting is one of the foundations for patient safety improvement, the large volume of data and the highly resource-intensive process for manual review can limit timely responsive action. We demonstrated that automatic categorisation of incident narratives is highly comparable to resource-intensive expert classification with high accuracy rates for incidents related to handover and patient identification.
We have developed the first classification for incidents involving e-health systems. This paper was cited in the 2011 US Institute of Medicine (IOM)’s report on the safety of e-health as providing “new data” about the risks of e-health to patient safety. Our classification is currently being used to categorise incident reports from the UK National Health Service in England and Wales.
In our study on clinical trials involving cholesterol-modifying drugs, we examined the differences between industry and non-industry funding on trial design. The study showed that industry-funded trials are larger, faster, less likely to consider safety outcomes and just as unevenly-distributed across the classes of drugs as non-industry trials.
In a second study we looked how industry-affiliated authors contribute to the evidence base. We found that these authors were more central in co-authorship networks, and tend to receive a greater number of citations. The study raises concerns about the level of influence industry-based authors have over the evidence used to change clinical decision-making.
The development of effective interventions to minimize the risks of poor quality care remains elusive and progress in effecting substantial change in the quality of care has been slow internationally. The publication of our novel proposal for a system-wide model to control adverse events, based upon ‘cap and trade’ has made a significant contribution at the highest level internationally to exploring how we can model systemlevel interventions, and how they might be engineered.
To assist in determining the efficacy of aviation-style Crew Resource Management (CRM) training in improving teamwork and patient safety, we conducted a randomised controlled trial of a CRM training intervention. Main outcome measures consisted of pre- and post-test quantitative participant teamwork attitudes, and post-test quantitative trainee reactions, knowledge and behaviour.
Positive changes were found in knowledge (mean difference 1•50, 95% CI 0•58 to 2•43, P=0•002), self-assessed teamwork behaviour (mean difference 2•69, 95% CI 0•90 to 6•13, P=0•009) and independently observed teamwork behaviour (mean difference 2•30, 95% CI 0•30 to 4•30, P=0•027) when the classroom trained group was compared with the control. Our study provides a substantial contribution to the small body of high quality evidence in relation to the efficacy of classroom CRM training in health care.
Globally health service accreditation is a strategy being used by governments to promote and assess the quality and safety of care. The evidence to support the investment in effort and resources in accreditation is indeterminate. We have undertaken the largest study to examine the relationships between accreditation outcomes and organisational and clinical performance and consumer involvement.
Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted.
The findings from this study, and associated accreditation research work, have been drawn up by accreditation agencies nationally and internationally, the International Society for Quality in Health Care (ISQua) and informed the Australian Commission on Safety and Quality in Health Care (ACSQHC) work in reforming the accreditation programs nationally.
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