Politics and publishing: the Quality in Australian Health Care Study

"In medical research, the real news is the evidence, not the public claim"

MJA 1995; 163: 453-454

The first of June 1995 may well be recorded in the chronicles of Australian health care as a black day for Australian hospitals. On that day, just before a meeting of the Australian Health Ministers' Forum, the Federal Minister for Human Services and Health presented the preliminary findings of the Quality in Australian Health Care Study (QAHCS) to Federal Parliament: that in 1992 an adverse event occurred in 16% of over 14 000 admissions to 28 public and private hospitals in New South Wales and South Australia. (An adverse event was defined as an unintended injury which resulted in a disability, including a longer hospital stay or death, which was caused by health care management rather than the patient's underlying disease.) Half the adverse events were regarded as preventable and a fifth were associated with degrees of permanent disability or death. The Minister reported that the study methods allowed the findings to be applied to the Australian hospital system as a whole. Thus, in 1992, 230 000 patients admitted to public and private hospitals would have had a preventable adverse event and up to 14 000 preventable deaths would have occurred.1 The high profile public release of the QAHCS preliminary information was accompanied by widespread and sensational coverage by the mass media and the medical media.2-4 The Minister's abridged version of the QAHCS data was viewed with disquiet, scepticism, frustration and even anger by a medical profession accustomed to the orderly progression of research information through peer review to comprehensive publication. The tradition of publishing health care research in peer-reviewed scientific journals before it is promulgated supposedly reduces the likelihood of confusion, exaggerated or unsubstantiated claims, self-promotion and exploitation.5-7 It allows health care professionals an opportunity to scrutinise the methods, assess the relevance of the results and independently judge the merits of the data presented. Five months later, the details of the QAHCS are published in this issue of the Journal (page 458) <eMJA pdf>. McNeil and Leeder provide a circumspect overview of the QAHCS findings and their implications (page 472), and Brennan examines the QAHCS in the context of the efforts in the United States to define patient safety in hospitals and proposals to introduce no-fault compensation schemes (page 475). The publication of the QAHCS affords an opportunity to outline the Medical Journal of Australia's policy on prior public release of material being considered for submission and eventual publication in the Journal. The Journal's policy accords with that of the International Committee of Medical Journal Editors (Vancouver Group).8 These guidelines extend and refine the Ingelfinger Rule, originally formulated by Dr Franz J Ingelfinger, a past Editor of the New England Journal of Medicine.9 The Vancouver Group acknowledges the need for editors to foster the orderly transmission of medical information, from the researchers, through peer-reviewed journals, to the health care professions and the public at large. There is an agreement with authors that no publicity, beyond that attending data presentation at scientific meetings (with certain qualifications), will occur while the information is under consideration by the journal or awaiting publication. There is also an agreement (known as the embargo) between the editor of the journal and the media that no prepublication release of information will occur. In return, editors facilitate media reports by providing journalists with press releases, advance copies of the journal or by refer- ring journalists to the appropriate experts for additional comments. These guidelines govern the relations between medical researchers, editors and the public media. The Federal Minister of Human Services and Health, however, is patently not a researcher but a politician. With the increasing separation of governments' roles as funders of health care services and their roles as providers of these services, politicians are progressively assuming the mantle of "protectors of the public good". At the same time governments are exploring methods of measuring quality of health care by clinical outcomes, a paradigm shift detailed in the article by Collopy et al. on the development of clinical indicators by the Australian Council of Healthcare Standards and the medical colleges (page 477). The Minister presented the results of the QAHCS in advance of a formal report because Australian health care consumers, professionals and policymakers "have a right to know" such information as soon as possible in order to formulate appropriate responses.1 There is no denying that the public is entitled to be informed of important health care information without unreasonable delay. Indirectly, the public owns most health care research in Australia because it is predominantly funded by their taxes. In many studies, they also contribute their personal involvement and goodwill. And it is, after all, their health that is at stake. However, it is also important that the public is not misled or misinformed, as is likely to occur in the absence of validated comprehensive information. As Relman, the immediate past Editor of the New England Journal of Medicine, has so eloquently stated: "In medical research, the real news is the evidence, not the public claim."6 In reality, little medical or public health research has such clear and urgent implications for the general public good that the news must be released to the public media before its critical evaluation and publication in a reputable journal. The findings of the QAHCS were judged by the Minister to be of such concern as to warrant early release. An immediate outcome of the ministerial statement was the creation of a high level taskforce, chaired by the Director of the Australian Institute of Health and Welfare, which has since sought public and professional submissions on processes to ensure quality in Australian hospitals. One wonders how the profession and the public were expected to make constructive comments without access to the details of the study. Now that the readers of the Journal can scrutinise the findings of the QAHCS, they can judge for themselves the appropriateness or wisdom of the political decision to release the abbreviated findings before formal publication. Martin B Van Der Weyden Editor, Medical Journal of Australia Ministerial Statement on Australian Hospital Care. Press release. 1 June 1995. (Published in full in Australian Medicine -- reference 2.) The Australian hospital care study: the results. Australian Medicine 1995; 7(12): 14. Baulderstone P. The politics of sick hospitals. Australian Medicine 1995; 7(12): 12-13. Cordner SM. Australia's preventable hospital deaths. Lancet 1995; 345: 1562. Relman AS. Reporting the aspirin study. The Journal and the media. N Engl J Med 1988; 318: 918-920. Relman AS. More on the Ingelfinger Rule. N Engl J Med 1988; 318: 1125-1126. Angell M, Kassirer JP. The Ingelfinger Rule revisited. N Engl J Med 1991; 325: 1371-1373. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Philadelphia: URM Secretariat Office, 1994. Definition of "sole contribution" [editorial]. N Engl J Med 1969; 281: 676-677.