Restructuring hospital services

In this issue of the Journal, Caplan and colleagues¹ (page 247) report the impact of a new system for managing elective surgery. Two groups of patients undergoing elective surgery were compared, one before and the other after a re-engineered system of coordinated care was introduced. The changes included preadmission assessment, improved patient education, admission to hospital on the day of surgery and postacute care after discharge.²Most patients, both day-surgery and longer-stay patients, were admitted on the day of operation, thus eliminating the need for an extra night in hospital for investigations and assessment. The new system resulted in a shorter length of stay, reduced risk of wound infection and a higher level of patient satisfaction.

The results of this study, which is an Australian first, are important for several reasons. The stereotypical image of healthcare sees managers as intent on saving money with no concern for quality of care, which contrasts with clinicians, who are seen as guardians of quality of care with no concern for cost. The study of Caplan et al demonstrates that the goals of health managers and clinicians can coincide. The patients' shorter stay freed up scarce hospital beds without compromising care, the patients were in favour of the shorter hospital stay, and wound infection rates were lower. Perhaps there is a potential for implementing innovative healthcare delivery systems which are both more efficient and provide equal or even improved quality of care. We will not know until we begin to vigorously evaluate the effects of new ways of organising healthcare delivery.

It is regrettable that the present health research agenda in Australia does not extend to evaluation of the performance of healthcare systems. Clinical and biological research seems to be much more highly valued. National research bodies have traditionally funded scientists with track records in more conventional and reductionist research (usually in a single specialised area) rather than in broad system evaluation. Health system research may involve moving out of one's specialty, department or laboratory. The re-engineered system described by Caplan et al¹ involved radically reorganising the role of anaesthetists and surgeons, and enlisting support and cooperation from many other hospital departments. The impact of the new system was then comprehensively evaluated, which is a major achievement in itself.

Randomised controlled trials involving a drug or single intervention are relatively straightforward. Evaluating a system presents greater challenges. Wide-ranging research expertise covering epidemiology, social sciences and health economics is required. Clinicians are an essential part of the research team. They are often driving the change and, as with a new drug or intervention, they need to know how the changes will affect their patients.

It is important to use new or more relevant research methods that serve the scientific question,^3-5 rather than to restrict the scope of the question to fit more conventional research tools.

Another challenge is having research which crosses many boundaries recognised by peer reviewers with specialised expertise. Acceptance of research by scientific journals is often determined more by the small size of the P value than by the relevance, importance or originality of the research. Health system research usually requires evaluations of many issues from many perspectives by many methods, including qualitative and quantitative, with investigators from different backgrounds working together to produce an integrated evaluation.⁵

We must be sceptical about health system changes which concentrate only on increased efficiency and cost savings. Introducing re-engineered health systems may have important implications for patient care. For example, in the study of Caplan et al there was no provision for evaluating the effect of early discharge on carers and patients. Future studies should also address these issues. Evaluating better and more efficient ways of delivering healthcare is just as important as developing and evaluating increasingly costly drugs and procedures.

Ken M Hillman
Professor; and Director,
The Simpson Centre for Health Service Innovation
Liverpool Hospital, Sydney, NSW

1. Caplan G, Brown A, Crowe PJ, et al. Re-engineering the elective surgical service of a tertiary hospital: a historical controlled trial. Med J Aust 1998; 169: 247-256.
   
2. Kerridge R, Lee A, Latchford E, et al. The perioperative system: a new approach to managing elective surgery. Anaesth Intens Care 1995; 23: 591-596.
   
3. Wyatt J, Spiegelhalter D. Evaluating medical expert systems: what to test and how? Med Info 1990; 15: 205-217.
   
4. Langley G, Nolan K, Nolan T. The foundation of improvement. Quality Progress 1994; (June): 81-86.
   
5. Heathfield H, Pitty D, Hanka R. Evaluating information technology in health care: barriers and challenges. BMJ 1998; 316: 1959-1961.