To the Editor: Francis and colleagues revealed a significant 29-minute decrease in the median emergency department (ED) length of stay and reductions in mean turnaround times for full blood count requests following the redesign of pathology processes.1 Laboratory performance and clinician satisfaction are intrinsically bound up with the timeliness of test results, not least because of their effects on patient diagnosis and treatment. The association between test turnaround times and ED length of stay is difficult to decipher. The reasons for this, as pointed out by Francis et al, include the many potential variables that contribute to patient length of stay in EDs. Turnaround times can also vary dramatically according to laboratory operating procedures and work processes. Nevertheless, there is a strong imperative to monitor these indicators as contributors to designing effective interventions to improve the quality and outcomes of patient care.

Our research has also revealed that pathology test turnaround times are a significant contributor to ED length of stay at a major teaching hospital in Sydney. Using regression analysis to account for a number of contributing length-of-stay variables (eg, triage category, patient age, number of tests ordered), we produced a model that accounted for 25.4% of the variance in ED length of stay, of which pathology test turnaround time was a significant contributor.2 Further, studies of the effects of electronic test-ordering systems on test turnaround times in five Australian hospitals have shown that introduction of these systems in each instance was associated with significant declines in test turnaround times.2-4 Thus, there appears to be converging evidence of a relationship between efficient test ordering and processing and reduced ED length of stay.5 In addition to the types of interventions described by Francis et al, electronic test ordering should be considered as a system-wide intervention that may contribute to improved efficiency and patient outcomes. Decision support within such systems provides an added ability to provide alerts and guidance in the test-ordering process.

In reply: A recent report on the state of Australian public hospitals highlights figures of 320.6 emergency presentations per 1000 weighted population, with 88% of presentations being triage categories 1–4, and 66% of patients not admitted.1 In our experience, pathology tests are performed on more than 50% of patients in these triage categories who present to emergency departments, and decisions regarding patient care are delayed pending availability of test results. In addition to the initiatives that we described,2 Georgiou and Westbrook describe other initiatives that deliver significant, sustained improvements in health care efficiency.

Many have emphasised the need to improve efficiency in the health care system by utilising evidence-based best practice. However, a recently published discussion paper highlights the challenges associated with ensuring that health care workers have access to, and actually use, evidence-based processes and protocols that have been shown to benefit patients.3 Similarly, delays in care may contribute to patient harm, and decisions about resource allocation and organisational systems do not always explicitly take this risk into consideration.3

These challenges may be partly related to the different funding arrangements in the Australian health care system. Apart from the obvious federal–state dichotomy, diagnostics, such as pathology services, and the associated information technology are often funded separately to the hospitals and health care professionals relying on these services. As a result, one of the challenges of implementing initiatives that improve efficiency relates to current and historical allocative funding arrangements, where costs may be borne by one cost centre, and benefits are delivered to patients and other elements of the health care system (ie, other health care providers and departments).

It is essential that the Productivity Commission4 considers all of these elements in its review to identify significant efficiency improvements within the hospital system. Effectiveness, allocative efficiency and dynamic efficiency are just as important as simple economic efficiency. Unnecessary delays in the health care system are not only associated with capital costs — they are also associated with an array of direct and indirect costs related to caring for patients who endure an unnecessarily protracted journey through the health care system.

It will take courage and commitment to implement and achieve appropriate use of evidence-based care (perhaps via mandates3) and appropriately fund all elements of patient care, so that improvements in care and overall cost savings are not hindered by historical funding constraints.