Matters arising

Health services administration
Volume 197 - Issue 10

CareTrack: assessing the appropriateness of health care delivery in Australia

Author:  Sean Mackay

Med J Aust 2012; 197 (10): 548. || doi: 10.5694/mja12.11186
Published online: 19 November 2012
To the Editor: The article by Runciman and colleagues1 has attracted much interest within the profession and in the lay press. However, there are serious methodological flaws in their study. The first issue is with the choice of clinical guidelines for assessing patient care. Although we have evidence for what is “best” practice in some areas, we are lacking this evidence in others. Hence, many of ...
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To the Editor: The article by Runciman and colleagues1 has attracted much interest within the profession and in the lay press. However, there are serious methodological flaws in their study.

The first issue is with the choice of clinical guidelines for assessing patient care. Although we have evidence for what is “best” practice in some areas, we are lacking this evidence in others. Hence, many of the guidelines used as the reference point for “appropriateness” of care are based only on expert opinion. Problematically, this means that one view is defined as the gold standard, and care provided according to alternative opinion is defined as deficient in some way. This is clearly unreasonable. The authors have been too ambitious in assessing many areas of clinical care, rather than limiting the study to areas with strong evidence bases.

The second issue is that there was no attempt to measure the quality of care actually delivered, only compliance with the guidelines. It seems that a patient who has been treated with a β-blocker for 15 years for essential hypertension and who has impeccable blood pressure control, but who has not experienced any side effects, would be classified as receiving “inappropriate” care. If this patient were changed to an angiotensin-converting enzyme inhibitor and developed a cough, then it seems the research team would give the treating doctor a tick of approval, because he or she is now compliant with the guidelines. If a research project attempts to comment on the quality of care delivered to patients, it needs to actually measure the quality of that care. In this respect, Runciman et al fail.

It is disappointing that this potentially contentious study was published in this form by the Journal. As always, the impact of the original is greater than that of the commentary that follows.

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