Volume 170 Issue 7

Research Rainfall, evaporation and the risk of non-contact anterior cruciate ligament injury in the Australian Football League John Orchard, Hugh Seward, Jeanne McGivern and Simon Hood MJA 1999; 170: 304-306 Abstract - Introduction - Methods - Results - Discussion - Acknowledgement - References - Authors' details - - More articles on Emergency medicine Abstract Objective: To determine if weather conditions affect the risk of anterior cruciate ligament (ACL) tear in Australian Football. Design: Prospective observational analytic study of football matches. Setting: The Australian Football League (AFL), a professional competition. Participants: All players in 2280 matches from 1992-1998. Main outcome measures: Surgically-proven ACL injury, not involving a direct contact mechanism, during a match; rainfall; water evaporation. Results: 59 ACL injuries not involving direct contact occurred during the study period, more commonly in cities north of Melbourne (χ2 = 17.0; df = 1; P < 0.001). Senior grade matches (relative risk [RR], 3.03; 95% confidence interval [CI], 1.52-6.03), high water evaporation in the month before the match (RR, 2.80; 95% CI, 1.53-5.10) and low rainfall in the year before the match (RR, 1.93; 95% CI, 1.12-3.34) were significantly associated with these injuries. Conclusion: Low water evaporation and high rainfall significantly lower the risk of ACL injuries in AFL footballers. The likely mechanism is a softening of the ground, which lowers shoe-surface traction. Consistent extra watering and covering of grounds during periods of high water evaporation may lower the rate of ACL injuries. Introduction Anterior cruciate ligament (ACL) injuries of the knee are the most costly injuries in football at both professional and amateur levels. Of the commonly occurring injuries, they are the most devastating for the player, as they usually require reconstruction and long term rehabilitation in order to retain normal knee function. In the Australian Football League (AFL), ACL injuries account for 12% of all missed playing time,1 which costs the competition over $1 million annually in injury payments alone. The rate of ACL injury in the AFL competition has increased over recent years.2 The exact numbers and costs of ACL injuries in amateur football are unknown. One report that tried to estimate the cost of sports injuries in Australia3 suggested that the cost of ACL injuries in all grades and codes of football was at least 10% of the nation's entire bill for sports injuries. It estimated 5000 football-related ACL injuries in Australia annually, directly costing $5000 each (not including lost work time and the increased susceptibility to later knee problems caused by these injuries).4 Recent studies have noted that there have been relatively more ACL injuries in the early months of the AFL season, in non-Victorian games, and in recent seasons of dry weather.2,5 Our aim was to examine the strength of the relationship of weather conditions to ACL injury. Methods We studied 2280 matches (all AFL home and away season, finals, reserve grade and Ansett Cup matches which occurred from 1992-1998 in the cities of Adelaide, Brisbane, Canberra, Darwin, Geelong, Hobart, Melbourne, Perth and Sydney), involving 2239 individual players. Approximately 75% of the matches were held in Melbourne, 5% to the south (Geelong and Hobart) and the remaining 20% in the northern cities. The occurrence of ACL injuries was determined by an ongoing injury surveillance program, which has attempted to determine the cause of every game missed through injury of listed players. The accuracy of this survey in determining the cause of missed games reached 100% in 1997, and has been greater than 90% in every year.1 In addition, a separate register for ACL injuries is held by the AFL. ACL injuries in the AFL are managed surgically and have the diagnosis proven at the time of simultaneous arthroscopy and reconstruction. The mechanism of injury was recorded by team doctors and divided into the categories of direct contact (where the player's knee or leg was contacted by another player) and no direct contact (which was subdivided into indirect contact and no contact). Daily weather variables were measured prospectively (but obtained by us retrospectively) by the Bureau of Meteorology at central locations in each city studied. No differentiation was made between rainfall in the differing suburbs of any city, except for Waverley Park (30 km from the centre of Melbourne), for which rainfall data were taken from the nearest centre (Moorabbin). Maximum and minimum temperature of the day of the match, rainfall, water evaporation and maximum wind gust were the raw weather variables considered. Water evaporation is a meteorological variable measuring the change of surface water into water vapour -- it is affected by temperature, sunshine, humidity and wind.6 Composite rainfall and evaporation variables were created (measuring the totals for the previous 7, 14, 28, 90 and 365 days), which were considered to have had potentially more effect on ground conditions than the weather only on the day of the match. Statistical analysis was carried out using SPSS for Windows.7 Chi-square and t tests (after variances assessed using Levene's test) were performed in the initial stages of the analysis. Multivariate analysis was performed using a logistic regression forward stepwise technique, with a significance of 0.05 to enter the equation. Continuous variables in the logistic regression were redefined into binary variables based on group median values, to calculate risk ratios adjusted for confounding. Results There were 111 surgically-proven ACL tears recorded in AFL players during the study period. Excluded from analysis were 33 injuries that did not occur in AFL matches (13 occurred during practice matches, 14 during training sessions and six in other league matches). Of the 78 injuries in AFL matches, 19 occurred through direct contact, 15 involved indirect contact (to another part of the body than the leg) and there was no contact involved in 44. Overall, games played north of Melbourne had a significantly higher rate of all ACL injuries (Table). However, injuries involving contact were not significantly associated with being north of Melbourne, although indirect-contact injuries were more common north of Melbourne. For the 59 ACL injuries that did not involve direct contact, the most predictive rainfall and evaporation variables for ACL injury were 28-day evaporation (t = - 3.8; df = 59; P < 0.001) and 365-day rainfall (t = 1.34; df = 2278; P = 0.18). Other significant associations were higher grade of match (t = 4.8; df = 59; P < 0.001), lower minimum temperature (t = - 3.7; df = 59; P < 0.001) and month (fewer injuries in winter) (t = 3.1; df = 2278; P = 0.002). Non-significant associations were night games (t = - 1.7; df = 59; P = 0.09) and wind speed (t = - 0.18; df = 2278; P = 0.86). Although 365-day rainfall was not significant according to the t test, this variable was entered into the logistic regression equation as significant. This is because of the confounding effect of evaporation -- venues with high evaporation also tend to have high rainfall. In a multivariate analysis including evaporation, variance in rainfall is more significant than when rainfall is considered alone. In contrast, night games and minimum temperature had less significance in the logistic regression model. All variables were considered in a logistic regression model with match grade, 28-day evaporation and 365-day rainfall qualifying to be entered into the equation. Senior grade matches had a 3.03-times risk of injury compared with reserve grade matches (95% confidence interval [CI], 1.52-6.03). Matches with high evaporation in the previous 28 days (> 48 mm) had a 2.80-times greater risk of injury (95% CI, 1.52-6.03). Matches with low rainfall (< 449 mm) in the previous year had a 1.93-times greater risk of injury (95% CI, 1.12-6.03). Figures 1 and 2 illustrate a strong association between the rate of ACL injuries not involving direct contact and 28-day evaporation and 365-day rainfall, respectively, for the matches in Melbourne over the study period. Discussion Risk factors for injury can be divided into intrinsic (personal) and extrinsic (environmental). Two intrinsic risk factors for ACL injury have been established: female sex8-11 and narrowed intercondylar notch.12-14 In a recent study, both factors were prospectively followed, and it was concluded that narrow intercondylar notch accounts for the increased number of ACL tears seen in female athletes. At this stage, narrowed intercondylar notch is not a reversible risk factor, but it can be measured at the time of injury and used to counsel athletes on the risk of recurrence, particularly to the contralateral knee. The most promising extrinsic risk factors postulated relate to the shoe-surface interface. It has been hypothesised for many years that increasing traction between a football boot and the playing surface would cause an increase in the rate of knee injuries.15 A recent study showed that American football boots, with a greater number of cleats and higher torsional resistance, were prospectively associated with an increased number of ACL injuries.16 Our results show that high water evaporation in the month before and low rainfall in the year before an AFL match confer an increased risk of ACL injury. This relationship is strong for most injuries not involving contact, but may not apply when the mechanism of injury involves a direct blow to the knee. The mechanism of this association is almost certainly through ground-related factors (either soil moisture content or amount and/or quality of grass). Increased speed of the game on dry grounds may also be relevant. These results are in keeping with the theory that excessive shoe-surface traction is a risk factor for ACL injury. Friction and torsional resistance from football boots has been shown to be higher in dry conditions on natural grass compared with wet conditions.17 In a recent review of non-contact ACL injuries in American Football, it was noted that almost all injuries on natural grass occurred in dry conditions,18 but that review did not measure or control for conditions on days when injury did not occur. We found that the long term effects of rainfall and water evaporation (over a period of months) are more relevant than the amount of rainfall and evaporation on the day or in the days leading up to a match. Further studies are required to determine the exact mechanism by which this relationship occurs and what the effects of intervention would be. The AFL has embarked on a study, beginning with the 1998 season, where matches have ground hardness readings taken with a Penetrometer, a device used in horse racing to measure track hardness. Penetrometer results are reliable and correlate with the speed of races.19 The preliminary results of the AFL study confirm that low rainfall and high evaporation are associated with hard (low) Penetrometer readings (< 4.7 cm).20 We did not study differences between ground conditions in coastal and inland locations, as (except for Canberra) all the major AFL venues are currently in coastal cities. Further study could include inland cities, which may experience different ground conditions due to much colder and drier winters. Irrespective of their mechanism of action, the effects of high water evaporation and low rainfall could be reversed on football grounds by consistently watering grounds during times of lower rainfall and covering them during times of increased sunshine. If grounds were prepared in this way to simulate the ground conditions typically experienced in a Melbourne winter, the number of ACL injuries would almost certainly be reduced. This is unlikely to lead to an increase in injuries of other types, as overall injury rates are consistently higher outside Victoria than in Victoria.1,5 In rugby league in the United Kingdom, injury rates increased across the board when the season was changed from winter to summer,21,22 suggesting harder grounds may be a universal risk factor for football injuries. In AFL, the main competing concern would be whether games played on consistently softer grounds would be a lesser spectacle for the attending and television public. In amateur football, similar reductions in ACL injuries could probably be achieved, without the standard of spectacle being an issue. The cost of manipulating ground conditions might seem initially prohibitive in this environment, but when the massive cost of ACL injury is considered, great overall savings could be made. In conclusion, low water evaporation and high rainfall significantly lower the risk of non-contact ACL injuries in AFL footballers. The mechanism is likely to be a softer surface, with lower shoe-surface traction and consequently less force transferred to the knee in movements such as pivoting. Consistent extra watering and covering of grounds during times of high water evaporation (sunny, windy periods with no rain) is likely to lower the rate of these devastating and costly injuries. Acknowledgement The Australian Football League funds the AFL Injury Surveillance System from which data for this study were derived. References Orchard J, Wood T, Seward H. AFL injury report 1997. Football Record 1998; 87: 54-61. Seward H. Can ACL injuries be prevented? In: Australian Conference of Science and Medicine in Sport. Canberra: Sports Medicine Australia, 1997. Egger G. Sports injuries in Australia: causes, costs and prevention. Sydney: National Better Health Program, 1990. Deacon A, Bennell K, Kiss ZS, et al. Osteoarthritis of the knee in retired, elite Australian Rules footballers. Med J Aust 1997; 166: 187-190. Orchard J, Seward H, Garlick D. Ground conditions and AFL injuries. In: Australian Conference of Science and Medicine in Sport. Canberra: Sports Medicine Australia, 1997. Lewis R, editor. Meteorological glossary. 6th ed. London: HMSO Publications, 1991. SPSS for Windows [computer program]. Version 6.0. Chicago, Ill: SPSS Inc, 1992. Arendt E, Dick R. Knee injury patterns among men and women in collegiate basketball and soccer. NCAA data and review of the literature. Am J Sports Med 1995; 23: 694-701. Ferretti A, Papandrea P, Conteduca F. Knee ligament injuries in volleyball players. Am J Sports Med 1992; 20: 203-207. Gray J, Taunton J, McKenzie D. A survey of injuries to the anterior cruciate ligament of the knee in female basketball players. Int J Sports Med 1985; 6: 314-316. Bjordal J, Arnoy F, Hannestad B, Strand T. Epidemiology of anterior cruciate ligament injuries in soccer. Am J Sports Med 1997; 25: 341-345. Souryal T, Moore H, Evans J. Bilaterality in anterior cruciate ligament injuries: associated intercondylar notch stenosis. Am J Sports Med 1988; 16: 449-454. Shelbourne K, Facibene W, Hunt J. Radiographic and intraoperative intercondylar notch width measurements in men and women with unilateral and bilateral anterior cruciate ligament tears. Knee Surg Sports Traumatol Arthrosc 1997; 5: 229-233. Shelbourne K, Davis T, Klootwyk T. The relationship between intercondylar notch width of the femur and the incidence of anterior cruciate ligament tears: a prospective study. Am J Sports Med 1998; 26: 402-408. Torg J, Quendenfeld T, Landau B. The shoe-surface interface and its relationship to football knee injuries. J Sports Med 1974; 2: 261-269. Lambson R, Barnhill B, Higgins R. Football cleat design and its effect on anterior cruciate ligament injuries: a three year prospective study. Am J Sports Med 1996; 24: 155-159. Heidt R, Dormer S, Cawley P, et al. Differences in friction and torsional resistance in athletic shoe-turf surface interfaces. Am J Sports Med 1996; 24: 834-842. Scranton P, Whitesel J, Powell J, et al. A review of selected noncontact anterior cruciate ligament injuries in the National Football League. Foot Ankle Int 1997; 18: 772-776. Neylan J, Stubbs A. Assessing racetrack conditions: a review of available devices. Canberra: Rural Industries Research & Development Corporation, 1998. Orchard J. Measurement of football ground hardness using the racetrack Penetrometer [abstract]. Med Sci Sports Exer. In press, 1999. Hodgson Phillips L, Standen P, Batt M. Effects of seasonal change in rugby league on the incidence of injury. Br J Sports Med 1998; 32: 144-148. Gissane C, Jennings D, White J, Cumine A. Injury in summer rugby league football: the experiences of one club. Br J Sports Med 1998; 32: 149-152. (Received 30 Jul, accepted 28 Nov, 1998) Authors' details Sports Medicine Unit, University of New South Wales, Kensington, NSW. John Orchard, MB BS, FACSP, Visiting Fellow. Australian Football League Medical Officers Association, Melbourne, VIC. Hugh Seward, MB BS, FACSP, President; Jeanne McGivern, MB BS, FRCS, Club Medical Officer; Simon Hood, BAppSci(PE), Research Officer. Reprints: Dr J Orchard, South Sydney Sports Medicine, 111 Anzac Parade, Kensington, NSW 2033. Email: johnorchardATmsn.com.au Make a comment Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Back to text Back to text Back to text

John Orchard · Hugh Seward · Jeanne McGivern · Simon Hood

Viewpoint Privatisation of teaching hospitals Training and research may be poorly served by privatisation and commercial management of hospitals Peter M Brooks MJA 1999; 170: 321-322 Introduction - Private money - Public costs - References - Authors' details - - More articles on Education Introduction Australia's major academic health centres not only provide excellent healthcare, but are also involved in one of the most important aspects of the healthcare system -- the training of our future health professionals.1 Most teaching hospitals are also involved in basic and clinical research, and many have major research institutes on their campuses. This symbiosis of healthcare, research and training has served us well, but is now under considerable threat from the fiscal constraints within the healthcare system (particularly in Victoria, where, despite the increase in throughput and reduction in waiting lists as a consequence of casemix funding, there has been a decline in funding to hospitals in real terms).2 For NIH awards to medical schools see figure. Recently, the Victorian State government has moved to amalgamate and privatise several public health institutions, including one of Australia's most prestigious teaching hospitals, the Austin and Repatriation Medical Centre. Whatever contractual arrangements are finally determined for these privatisations, they must preserve the high standards and broad range of teaching, research and healthcare that the institutions currently provide, or else the saving of public money will eventually be to the detriment of the health of the community. Private money As economic rationalism has gripped the world over the past decade, governments of all persuasions have moved to privatise public utilities.3 In healthcare, governments have seen this as a way to inject much-needed capital into the system in order to keep pace with community expectations. The private sector has responded with willingness to invest in many aspects of the healthcare system. Some private hospitals have established research foundations which provide for research (primarily clinical) within their institutions or within universities or public hospitals. With private hospital collocation projects that have been developed in most states, including New South Wales and Victoria (and are being introduced in Queensland), the collocating private partners have provided funds for research and for academic/research/service positions. It is important to continue developing relationships between the private and public healthcare sectors in Australia, but both economic outcomes and the impact on the delivery of service, research and education need to be carefully monitored and evaluated. The "build-own-operate" projects which have been developed in Western Australia (Joondalup) and New South Wales (Port Macquarie) have already raised concerns as to whether the developments have led to real savings to the public sector.4 Similar concerns have been raised in Britain in relation to the Private Finance Initiative Program introduced in 1992, under which a National Health Service Trust enters into a contract with a private sector consortium that will design, build, own and manage a hospital and the Trust provides clinical services. Evaluation of these arrangements suggests that they lead to inefficient and inequitable allocation of scarce National Health Service resources.5 These arrangements also affect rational healthcare planning at a "macro" level and will make strategic planning more difficult, because commercial considerations (and commercial confidentiality) will intervene.6 Other risks of "privatisation" are that teaching and research may not be as well supported and that the privatised facility will concentrate on the high-return services at the expense of looking after the elderly and chronically ill. Public costs Healthcare reforms in the United States with the emergence of health maintenance organisations and managed care have led to significant problems for American academic centres.7 As pointed out by Blumenthal et al,8 academic health centres have a social mission to provide an integrated healthcare system for the community. Exposing these institutions to market forces has a significant impact on the stability of the three pillars of academic health centres -- training, research and patient care. There are now data available to suggest that medical schools in communities with a high level of managed care receive less National Institutes of Health funding than those in communities with low levels of managed care.9 Similarly, young clinical researchers in hospitals serving communities with a high level of managed care published fewer scientific articles and perceived greater levels of departmental conflict and decreased cooperation.10In Australia, our internationally recognised high standards of health professional training are maintained to a large extent by the undergraduate, graduate and postgraduate training within our major teaching hospitals. Providing young health professionals with the necessary clinical environment for learning significantly increases the institutional costs because of the extra time expended in routine clinical tasks, the requirements of supervision and the use of more diagnostic and therapeutic services by trainee health professionals. In the competitive market place of the United States, academic medical institutions have found it very difficult to maintain all their activities, as the healthcare purchasers tend to favour the lower-cost suppliers of services. Increasingly, American academics have to spend more time in direct clinical care and less in teaching and research.11 In Victoria, the "teaching, training and research" component of casemix definitions does provide additional funding to the teaching hospitals.12 Although this formula will be used in the contracts developed with the private sector organisations, it will be important to make sure that they actually deliver on their commitment to teaching and research.13 Private hospitals have a responsibility to their shareholders and have naturally concentrated their activities on those healthcare "products" that are profitable. This has seen a concentration in the private sector of diagnostic facilities and provision of elective surgical procedures such as total joint replacement. These private units provide excellent healthcare services, but do not contribute as much to research or teaching as their public counterparts. Basic research may be more adversely affected by a transition to privatised healthcare. Competitive healthcare markets fail to support significant amounts of basic research because the economic benefits of such work are uncertain, often long term and can rarely be fully realised by those who pay for them.14 Experience in the United States demonstrates that basic research is more likely to produce knowledge that has practical benefits when potential users are participating in the research or interacting with the investigators conducting the research.15 The Australian medical research community (albeit underfunded) has produced significant advances in our understanding of disease flowing from its basic research activities. Around the country, the most successful institutes have fostered a close association between clinicians and basic researchers. Private enterprise (particularly pharmaceutical companies) provides significant funds to public Australian research institutes, although this funding needs to be encouraged and increased.16 Whether privately funded institutes would succeed in raising more research funding is yet to be seen, but little or no basic research is conducted at Australian private hospitals. As Blake points out "economics should discipline, but not control, academic medicine and medical practice".17 Few people working within teaching hospitals or medical research institutes could fail to realise the importance of fiscal responsibility in the light of the economic rationalisation that has gone on within the Australian healthcare system over the past two decades. It is a little surprising that the academic institutions, health professionals and the general public have not been more vocal in their questioning of the Austin and Repatriation Medical Centre privatisation decision. I believe that our community is interested in the excellence of medical care, in training the medical workforce of the future and in seeing the continuing development of advances in healthcare through research. These values, however, do have to be voiced, and this should be done through persistent and persuasive academic leadership.17 The process currently in train in Victoria must be seen as an experiment. Like all clinical trials, it should be closely monitored, and terminated if it seems to be doing harm. If it continues, it must be evaluated to make sure that the result is a positive one -- for all parties. References Brooks PM, Goulston KJ. Future of medical training in Australia. Med J Aust 1998; 168: 504-505. Duckett SJ. Casemix in Victoria: a five year review. In: Stone C, Jonas H, editors. Privatising health care. Proceedings from the seminar "Privatising Health Care". Melbourne Public Health Association (Victorian Branch), June 1998. Canberra: Public Health Association Australia, 1998: 7-9. Ralston SJ. The unconscious civilization. Harmondsworth, UK: Penguin Books, 1997. Collyer F. Privatisation, cost efficiency and public accountability: the case of Port Macquarie Base Hospital. In: Stone C, Jonas H, editors. Privatising health care. Proceedings from the seminar "Privatising Health Care". Melbourne Public Health Association (Victorian Branch), June 1998. Canberra: Public Health Association Australia, 1998: 20-24. Gaffney D, Pollock AM. Can the NHS afford the private finance initiative? London: British Medical Association Health Policy and Economic Research Unit, 1997. Boyle S. The private finance initiative. BMJ 1997; 314: 1214. Iglehart J. The American health care system -- teaching hospitals. N Engl J Med 1993; 329: 1052-1056. Blumenthal D, Campbell EG, Weissman JS. The social mission of academic health centres. N Engl J Med 1997; 337: 1550-1553. Moy E, Mazzaschi AJ, Levin RJ, et al. Relationship between National Institutes of Health research awards to US medical schools and managed care market penetration. JAMA 1997; 278: 217-221. Campbell EG, Weissman JS, Blumenthal D. Relationship between market competition and the activities and attitudes of medical school faculty. JAMA 1997; 278: 222-226. Reuter J, Gaskin D. Academic health centres in competitive markets: How ACH's are coping with reduced revenue and increased competition for managed care patients. Health Aff (Millwood) 1997; 16(4): 242-252. Phillips PA. Teaching and research in a casemix funding environment. Med J Aust 1998; 169 Suppl: S53-S55. The role and responsibilities of the private sector in the provision of public hospital services in Victoria. Melbourne: AMA (Victorian Branch), Sept 1997. Blumenthal D, Causino N, Campbell E, Louis KS. Relationships between academic institutions and industry in the life sciences -- an industry survey. N Engl J Med 1996; 334: 368-373. Rosenberg N, Nelson RR. American universities and technical advance in industry. Res Policy 1994; 23: 323-348. Wills P (Chairman). The virtuous cycle -- working together for health and medical research. Report of the Health and Medical Research Strategic Review. Canberra: AGPS, 1998. Blake D. Whither academic values during the transition from academic medical cen- tres to integrated health delivery systems? Academic Med 1996; 17: 818-819. Authors' details Faculty of Health Sciences, University of Queensland, Brisbane, QLD. Peter M Brooks, MD, FAFPHM, FRACP, Executive Dean. Reprints will not be available from the author. Correspondence: Professor P M Brooks, Edith Cavell Building, Royal Brisbane Hospital, Herston, QLD 4029. Email: p.brooksATmailbox.uq.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Back to text

Peter M Brooks

For Debate The changing role of acute-care hospitals Acute-care hospitals are moving away from their central role in the healthcare system and becoming specialised institutions for the care of a particular kind of patient. Ken Hillman MJA 1999; 170: 325-328 For editorial comment, see Braithwaite & Hindle Introduction - The technological boom - System failure - Community care alternatives - A narrower role for the hospital? - Enter: a new specialty - Clinical experience and education - General practice and innovation - References - Authors' details - - More articles on Administration and health services Introduction The publicly funded acute-care hospital had its origins as a charitable institution.1 Until the middle part of this century, the working life of medical practitioners was predominantly based on private practice. Private patients were attended in doctors' rooms and, when necessary, usually cared for in small private hospitals.2 Large public hospitals were for the poor. The clinician would visit the public hospital for several hours each week to attend the poor and teaching and research were centred on these patients. Everyone seemingly gained. The sick received free care and the clinician's conscience and sense of righteousness were satisfied. Because private medical practitioners were accommodating the poor on a charitable basis, the hospital system was established around practitioners' needs. For example, surgeons had their own operating theatre, theatre nurse, ward, ward nursing staff and a cluster of junior doctors, usually organised in a hierarchical way, with house staff at the bottom and senior registrars-in-training at the top. Similar systems existed for other specialties, such as internal medicine and obstetrics. The legacy of these arrangements is that the acute-care hospital has grown in a haphazard way, resulting in inefficiencies, duplication and the development of a system that is often designed around medical practitioners rather than patients. This system is now clashing with increasing demands by consumers to be involved in their own care, pressures from funders for more financial accountability and changing technology in medical care. As a result, the nature and role of acute-care hospitals are undergoing upheaval. The technological boom Until as recently as 40 years ago, hospitals were mainly places for bedrest and convalescence. The range of surgical operations was limited, high-powered investigations and monitoring were almost non-existent and medical treatments were largely restricted to a small number of procedures and relatively simple drugs. Nature, more than medical interventions, determined whether patients recovered or not. An explosion of medical knowledge occurred in the 1950s. Complex surgery such as cardiac valve replacement, transplant surgery, microsurgery and complex cancer surgery became commonplace. Great advances occurred in anaesthesia, making the performance of these procedures possible. Intensive care units (ICUs) kept many patients alive who previously would not have survived. Physicians developed interventions such as endoscopy and chemotherapy. Investigations such as computed tomography expanded our knowledge of diseases and treatment options. Whereas previously all hospitals provided a similar range of options for patients, there now emerged a complex institution serviced by an expanding range of medical specialties, complemented by expensive technology. A two-tiered system of hospitals developed. One was limited in its range of expertise and technology, while the other was keeping abreast of all the rapidly emerging developments. The winners were the hospitals in the heart of capital cities. Outer metropolitan and rural hospitals increasingly had to refer patients to these centres of excellence. The reasons why some hospitals developed as centres of excellence and others did not are complex; it was largely related to the clustering of medical expertise in large, centrally located, university-affiliated hospitals. The developing expertise in one specialty was often dependent on similar rates of development in others, in order to perform increasingly sophisticated interventions. System failure Despite increasing specialisation and remarkable advances in technology, the fundamental organisation in hospitals has changed little. Concepts such as clinical directorates, clinical pathways, evidence-based medicine, benchmarking and quality improvement are to a greater or lesser extent affecting the way we manage patients in acute-care hospitals. However, patients are still admitted under an individual clinician who "owns" them; the patient is discharged at the admitting clinician's convenience; and, in the larger institutions, nursing staff, together with a hierarchy of junior medical staff, still manage the day-to-day care of the patient. Basic issues such as standardised indications and protocols for the admission and discharge process are usually not addressed and patient management is usually not well coordinated. The flow of patients through a hospital is often inefficient, dislocated and disorganised. While individual specialists and departments may deliver excellent individual standards of care, the system often falls apart at the interfaces of that care. For example, a patient may be operated on by the world's best plastic surgeon and be treated in a ward renowned for plastic surgical care, but, if the patient bleeds excessively, the system may soon be sorely tried. Let us imagine that the patient becomes tachycardic and hypotensive. Hypovolaemic shock is not a common occurrence in a plastic surgery ward. Vital signs are only recorded four-hourly. Nursing staff inform junior medical staff, who in turn inform up the hierarchy. The plastic surgery registrar may be a great technician, but often does not have formal training in management of the seriously ill and recent advances in resuscitation. Let us imagine further that the patient, as is increasingly common, has comorbidities such as underlying ischaemic heart disease, hypertension and chronic lung disease related to smoking. The patient has a myocardial infarction and things go from bad to worse. The system fails, because it is a system designed for performing procedures, somewhat at the convenience of doctors, and not a system for the coordinated care of patients. A sobering example of system failure has recently been widely reported.3 Between 10 000 and 14 000 preventable deaths may occur in Australian hospitals each year.4 Similar problems exist in other countries.5 Of course, this is the tip of the iceberg: for every preventable death, there are many potentially preventable serious complications. The incidence is the same whether the hospital is a small rural one, a large metropolitan hospital or a teaching and referral centre.4 This incidence of adverse events may worsen as hospital bed numbers are "downsized" and the remaining patients become more seriously ill and at risk of preventable death and complications. There is now enormous pressure to reduce hospital bed numbers, to cut hospital admissions and to reduce the length of stay in hospitals. Hospitals will have to respond by lifting the effectiveness of their system of care. Community care alternatives These pressures are largely due to financial constraints, yet it may not be such a bad thing for most patients to spend less time in hospital. Institutional care in hospitals is not necessarily the most sensitive and caring environment for many patients, including those who are dying, those requiring rehabilitation and those with mental illness. In other words, it may not only be cheaper but better for ambulant patients to be treated in more appropriate environments.6 As alternatives are developed, hospitals are restricting their function to managing patients who have serious, complex and potentially recoverable illnesses. Specialties such as psychiatry, geriatrics, rehabilitation and palliative care are increasingly becoming community based. Many investigations, even the more complex ones, are now being performed in the community. Up to 60% of patients are now having day-only surgery.7 Imaginative alternatives to hospital-based care are being developed. This is leading to a radical change, both for the broader healthcare picture and for the future of acute-care hospitals. A narrower role for the hospital? The acute-care hospital will, in the near future, care mainly for the sick who have a chance of recovering.8,9 Increasingly, in-hospital patients will have more complex problems and a greater number of comorbidities. Specialised units caring for the seriously ill are increasing. Emergency departments are increasingly managing the seriously ill rather than offering primary healthcare; operating suites are performing more complex procedures for in-hospital patients. As a result, far more intensive-care and high-dependency beds are required, while the total number of acute-care hospital beds is decreasing as the more ambulant and less sick are managed elsewhere.10Ironically, the increasing specialisation that has occurred over the last 40 years may not provide support for the changing population of hospital patients. Specialists will, of course, continue to provide specific expertise. Opinions will be sought on a particular problem or a specialised procedure will be performed, but modern specialists may not always be appropriate for providing overall care for a complex in-hospital patient.10-12 Increasingly, specialists who were once based almost entirely in a hospital setting are providing care for patients in ambulant and out-of-hospital settings. Enter: a new specialty These developments have led in some countries to the emergence of a "hospitalist"13 who has a wide range of expertise, but concentrating more on acute hospital medicine -- more like a general physician, but specialising in acute and serious illness rather than chronic and mainly ambulant medicine. The hospitalist also has advanced resuscitation and procedural skills. They are familiar with the medical comorbidities increasingly associated with surgical patients and understand how different organs fail and interact in acute illness. They are a move back to the generalist physician. The equivalent in Australia is probably the intensive care or emergency physician. The hospitalist also understands about continuity and coordination of patient care, managing the patient's in-patient course and arranging a seamless transition to a community setting.13The proponents of the hospitalists argue that, as hospital stay becomes shorter and more intense, it is unlikely that high value care can continue to be delivered by traditional specialists who spend only some of their day in an acute hospital setting and do not have the time to keep abreast of all the developments in acute-care and emergency medicine, or to maintain competence in acute-care resuscitation. It has always been the case that most acute hospital care is performed by the permanent hospital junior medical and nursing staff.11 The role of the specialist has changed little in that way over the last hundred years. Specialists manage their in-hospital patients at a distance, using rotating junior medical staff and nursing staff for most of the day-to-day care. A hospitalist could enable community-based specialists to devote more time to what they do best, rather than being continuously confronted by the dilemma of maintaining a busy professional practice with tight appointment schedules and having seriously ill in-hospital patients who might require their attention day or night in an unpredictable way. Having skilled clinical cover 24 hours a day would also help guarantee patient safety. However, there are many ways of achieving this goal, and, while the concept of a "hospitalist" may be working in the United States, Australia could explore other ways of achieving the same standards. Clinical experience and education The changing nature of acute-care hospitals will also have wide-ranging effects on undergraduate and postgraduate medical training in Australia.14,15 While many welcome changes have occurred in undergraduate training in Australia, the bulk of it remains based on hospital patients, who are in turn not only decreasing in number but (even more importantly) represent an increasingly limited part of the healthcare spectrum. Patients with the common problems on which undergraduate education was based are now managed in other environments, such as the specialist's rooms or in the community. Moreover, the skills necessary to manage an increasingly ill population of in-hospital patients have either never been taught, or are taught suboptimally.16,17 Similarly with postgraduate education. While physicians and surgeons may have had some exposure to emergency and intensive care medicine, there is currently no formal or obligatory requirement for training in advanced resuscitation. With increasing specialisation, this might become even more of a problem for physicians as their skills become more orientated to the less seriously ill and more ambulant patients. Moreover, hospital systems are poorly designed to deal 24 hours a day with the seriously ill. Up to 80% of in-hospital cardiac arrests are preceded, often for many hours, by slow and documented deterioration in vital signs.18 Among critically ill patients who do not have an arrest, there is a high incidence of serious complications that are not adequately managed in a timely fashion.19 Systems dealing with the seriously ill, such as those for trauma20 and acute in-hospital medical problems,21,22 are being developed in some centres but they are not, as yet, seen as fundamental to the care of the critically ill. In-hospital patients with cross-specialty problems are usually subject to a complex system of referral. This works well for non-life-threatening problems, but for the increasing population of at-risk patients in acute-care hospitals the lack of systems which work at the interfaces between specialists, professions and departments may be contributing to excessive mortality and morbidity.19,23 General practice and innovation The role of the general practitioner (GP) in the larger health picture is also being re-evaluated. While GPs have probably always seen acute-care hospitals as expensive and relatively insignificant players in the big healthcare picture, acute-care hospitals have, until recently, seen themselves as the self-appointed flagships of healthcare. Now GPs and community-based healthcare delivery are becoming more dominant in healthcare. Healthcare is being devolved back to them at a rapid rate, as acute-care hospitals attempt to decrease admission rates, reduce length of stay and facilitate early discharge. The way community health and hospital care interact is also being reinvented. Most Western countries are struggling with the issue of how to deliver better healthcare at the same or reduced cost. Australia has a unique opportunity to develop its own way of achieving this without necessarily slavishly adopting overseas systems such as managed care or seeing privatisation as a panacea for healthcare delivery problems. Already we are seeing many exciting Australian examples of innovation in this area. The New South Wales system of discrete Health Areas, with one authority being responsible for all acute-care hospital and community-based services, is proving an exciting platform for re-engineering health in innovative ways. The Commonwealth Government has funded innovative models developed by actively practising clinicians working together from community and acute-care hospitals (National Demonstration Hospital Programs). Hospitals will increasingly develop systems based on patient needs as well as the needs of the admitting clinicians. Community-based healthcare, including GPs, will provide most healthcare. Hospitals will treat fewer patients who are increasingly ill. Acute-care hospitals will become more specialised in their function and, as such, will probably be inappropriate platforms for comprehensive undergraduate and postgraduate medical training. Whether adequate funding to the community will follow this change in healthcare is debatable. As a result of these changes, it is crucial that we carefully and methodically devote more health research funding to evaluate the effects of these changes on patients. References Abel-Smith B. The hospitals 1800-1948. Heinemann, London 1964. Physicians, practitioners and fees. BMJ 1878; 1: 197-198. Bolsin S. Professional misconduct: the Bristol case. Med J Aust 1998; 169: 369-372. Wilson RMcL, Runciman WB, Gibbert RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Brennan TA, Leape LL, Laird N, et al. Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-376. Caplan GA, 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: 247-251. Morgan M, Beech R. Variations in lengths of stay and rates of day case surgery: implications for efficiency of surgical management. J Epidemiol Community Health 1990; 44: 90-105. Braithwaite J, Vining RF, Lazarus L. The boundaryless hospital. Aust N Z J Med 1994; 24: 565-571. Hillman KM. Reducing preventable deaths and containing costs: the expanding role of intensive care medicine. Med J Aust 1996; 164: 308-309. Moss F, McNicol M. Alternative models of organisation are needed. BMJ 1995; 310: 925-928. Smith J. Consultants of the future. BMJ 1995; 310: 953-954. Mather HM, Elkeles RS on behalf of the North West Thames Diabetes and Endocrinology Specialist Group. Attitudes of consultant physicians to the Calman proposals: a questionnaire study. BMJ 1995; 311: 1060-1062. Wachter RM, Goldman L. The emerging role of "hospitalists" in the American Health Care System. N Engl J Med 1996; 335: 514-517. Brooks PM, Goulston KJ. Future of medical training in Australia. Med J Aust 1998; 168: 504-505. Lawson KA, Armstrong RM, Van Der Weyden MB. A sea change in Australian education. Med J Aust 1998; 169: 653-658. Buchman TG, Dellinger RP, Raphaely RC, Todres ID. Undergraduate education in critical care medicine. Crit Care Med 1992; 20: 1595-1603. Harrison GA, Hillman KM, Fulde GWO, Jacques TC. The need for undergraduate education in crit care. Results of a questionnaire to Year 6 medical undergraduates, UNSW and recommendations on a curriculum in critical care. Anaesth Intensive Care 1999; 27: 53-58. Schein RMH, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 98: 1388-1392. McQuillan P, Pilkington S, Allan A, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998; 316: 1853-1858. Report of the Working Party on Trauma Systems. The National Road Trauma Advisory Council. Canberra: Commonwealth Department of Health, Housing, Local Government and Community Services, 1993. Lee A, Bishop G, Hillman KM. Daffurn K. The medical emergency team. Anaesth Intensive Care 1995; 23: 183-186. Hourihan F, Bishop G, Hillman KM, Daffurn K, Lee A. The medical emergency team: a new strategy to identify and intervene in high risk patients. Clin Intensive Care 1995; 6: 269-272. Lundberg JS, Perl TM, Wiblin T, et al. Septic shock: an analysis of outcomes for patients with onset on hospital wards. Crit Care Med 1998; 26: 1220-1024. Authors' details The Simpson Centre for Health Service Innovation, The University of New South Wales, Sydney, NSW. Ken Hillman, FRCA, FFICANZCA, Director, and Professor of Intensive Care. Reprints will not be available from the author. Correspondence: Professor K M Hillman, Co-Director, Division of Critical Care, The Liverpool Health Service, PO Box 103, Liverpool, NSW 2170. Email: k.hillmanATunsw.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> The hospitalist Cares for patients with complex acute illness Specialises in acute-care hospital medicine Makes a career wholly within the hospital system Has advanced resuscitation and procedural skills Knows the medical morbidities of surgical patients the interactive effects of organ systems in stress and failure Coordinates care for patients across departments, from doctor to doctor Ensures continuity of care for patients and through these skills and action Prevents hospital systems failure Back to text

Ken Hillman