Identifying and acting on potentially inappropriate care

Stephen J Duckett, Peter Breadon and Danielle Romanes
Med J Aust 2015; 203 (4): 183. || doi: 10.5694/mja15.00025


Objective: To develop a model to measure potentially inappropriate care in Australian hospitals.

Design: Secondary analysis of computerised hospital discharge data for all Australian hospitals for the 2010–11 financial year.

Main outcome measure: Hospital-specific incidence of selected diagnosis–procedure pairs identified as inappropriate in other literature.

Results: Five hospital procedures that are not supported by clinical evidence happened more than 100 times a week, on average. The most frequent of these do-not-do treatments was hyperbaric oxygen therapy for a range of specific conditions (4659 admissions in 2010–11). The rate of do-not-do procedures varied greatly, even among comparator hospitals that provided the procedure and that treated the relevant patient group. Among comparator hospitals, an average of 3.3% of patients with osteoarthritis of the knee received arthroscopic lavage and debridement of the knee (a do-not-do treatment), but four hospitals had rates of over 20%. There was also great variation in hospital-specific rates of procedures that should not be done routinely.

Conclusion: Hospital-specific rates of do-not-do treatments vary greatly. Hospitals should be informed about their relative performance. Hospitals that have sustained, high rates of do-not-do treatments should be subject to external clinical review by expert peers.

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  • Stephen J Duckett
  • Peter Breadon
  • Danielle Romanes

  • Grattan Institute, Melbourne, VIC

Competing interests:

No relevant disclosures.

  • 1. Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973; 182: 1102-1108.
  • 2. Wennberg JE. Forty years of unwarranted variation — and still counting. Health Policy 2014; 114: 1-2.
  • 3. Organisation for Economic Co-operation and Development. Geographic variations in health care: what do we know and what can be done to improve health system performance? OECD Health Policy Studies. Paris: OECD Publishing, 2014.
  • 4. Australian Commission on Safety and Quality in Health Care, Australian Institute of Health and Welfare. Exploring healthcare variation in Australia: analyses resulting from an OECD study. Sydney: ACSQHC, 2014.
  • 5. Evans RG. The dog in the night-time: medical practice variations and health policy. In: Andersen TF, Mooney G, editors. The challenges of medical practice variations. London: MacMillan Press, 1990: 117-152.
  • 6. Mercuri M, Gafni A. Medical practice variations: what the literature tells us (or does not) about what are warranted and unwarranted variations. J Eval Clin Pract 2011; 17: 671-677.
  • 7. Goodman DC. Unwarranted variation in pediatric medical care. Pediatr Clin North Am 2009; 56: 745-755.
  • 8. Elshaug AG, McWilliams JM, Landon BE. The value of low-value lists. JAMA 2013; 309: 775-776.
  • 9. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. Med J Aust 2012; 197: 556-560. <MJA full text>
  • 10. Prasad V, Vandross A, Toomey C, et al. A decade of reversal: an analysis of 146 contradicted medical practices. Mayo Clin Proc 2013; 88: 790-798.
  • 11. Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009; 361: 569-579.
  • 12. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009; 361: 557-568.
  • 13. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347: 81-88.
  • 14. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2008; 359: 1097-1107.
  • 15. National Institute for Health and Clinical Excellence. Laparoscopic uterine nerve ablation (LUNA) for chronic pelvic pain. London: NICE, 2007. (NICE Interventional Procedure Guidance 234.)
  • 16. National Institute for Health and Care Excellence. Heavy menstrual bleeding. London: NICE, 2007. (NICE Clinical Guideline 44.)
  • 17. Medical Services Advisory Committee. Hyperbaric oxygen therapy. Canberra: MSAC, 2000. (MSAC applications 1018-1020. Assessment report.)
  • 18. Medical Services Advisory Committee. 1054 - Hyperbaric oxygen therapy for the treatment of non-healing, refractory wounds in non-diabetic patients and refractory soft tissue radiation injuries. MSAC, 2003.
  • 19. Medical Services Advisory Committee. Reconsideration of Application 1054.1: Hyperbaric oxygen treatment (HBOT) for non-diabetic chronic wounds. MSAC, 2012.
  • 20. National Institute for Health and Care Excellence. Dyspepsia: management of dyspepsia in adults in primary care. (NICE Clinical Guideline 17.) London: NICE, 2004.
  • 21. National Institute for Health and Care Excellence. Intrapartum care: care of healthy women and their babies during childbirth. (NICE Clinical Guideline 55.) London: NICE, 2007.
  • 22. National Institute for Health and Care Excellence. Induction of labour. (Clinical Guideline 70.) London: NICE, 2008.
  • 23. Schwartz AL, Landon BE, Elshaug AG, et al. Measuring low-value care in Medicare. JAMA Intern Med 2014; 174: 1067-1076.


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access_time 06:34, 24 August 2015
Ian A Harris

We thank the authors for highlighting the problem of inappropriate care, particularly related to knee arthroscopy, on which we have previously published.[1, 2] However, we feel that the methods used may have underestimated the extent of the problem by concluding that there were only 813 procedures in the year under study.

Using MBS data alone (which does not include public patients in public hospitals or compensation scheme patients) we found that there were nearly 60,000 knee arthroscopies performed in the 2010-2011 financial year. It is known that most knee arthroscopies are done for degenerative conditions for which the procedure is of no benefit compared to placebo, with approximately 60% of procedures occurring in patients aged 45 or older. We have found the diagnostic coding to be unreliable, and the restriction to a diagnosis of osteoarthritis, and perhaps restricting the procedure codes, might explain the total number of 813 knee arthroscopies in one year.

By reducing the number of knee arthroscopies from 60,000 to 813, we feel that the extent of the problem has been vastly underestimated and the variation shown is more likely to reflect non-clinical factors such as diagnosis and procedure coding variations.

If the number of 813 unnecessary arthroscopies was correct, we would feel that the problem had been virtually solved. Unfortunately, we estimate the number to be much higher.

1. Buchbinder R, Harris IA, Sprowson A: Management of degenerative meniscal tears and the role of surgery. BMJ 2015, 350:h2212.
2. Buchbinder R, Richards B, Harris I: Knee osteoarthritis and role for surgical intervention: lessons learned from randomized clinical trials and population-based cohorts. Current Opinion in Rheumatology 2014, 26(2):138-144.

Competing Interests: No relevant disclosures

Prof Ian A Harris

access_time 02:57, 3 September 2015
Stephen Duckett

Harris and Buchbinder are right to note that our approach to identifying questionable care is very conservative. Because we sought to identify questionable care with as much confidence as possible, we gave clinicians the benefit of the doubt wherever we could. We believe this is a constructive approach. Being less cautious could easily provoke the disbelieving and dismissive reactions described in Ibrahim’s editorial*.

Our result may only identify the tip of the iceberg, but that is a great place to start looking for ice. If some shows above the waterline, there might be much more below.

We argued that hospitals providing do-not-do arthroscopies at above the average rate should have their practices reviewed. When an expert clinical team investigates the use of arthroscopies in those hospitals, their review could look at arthroscopies in general, not just the narrow do-not-do category that we used. These reviews could have a big impact on care. The hospitals with above average rates of do-not-do arthroscopies provide one quarter of all arthroscopies (these figures are for public hospitals only).

In most cases, it takes more than routine hospital data to evaluate treatment choices conclusively. The data can identify hospitals that almost certainly have some poor clinical decision-making, and which may have much more. By focusing on the most reliable red flag for questionable care, clinical reviews have the best chance of improving care and protecting patients from unnecessary treatments.
* Ibrahim, J. E. (2015). It is not appropriate to dismiss inappropriate care. The Medical journal of Australia, 203(4), 161

Competing Interests: No relevant disclosures

Dr Stephen Duckett
Grattan Institute

access_time 12:57, 8 September 2015
Sanjay Sharma

The issue of inappropriate care raised by Duckett et al (1) is an important and timely reminder to all health professionals and institutions participating in patient care. Disbelief and a dismissive approach (2) are frequent responses to such reports, which need to be replaced by strategies for improvement.

The study has over-representation of inappropriate care in patients receiving hyperbaric oxygen therapy, and we would like to draw attention to the fact that inappropriate care occurs in various other medical disciplines. There are numerous reports of inappropriate coronary interventions (3) and endoscopies (4).

Another area of patient care in the hospitals that goes unnoticed or unreported is inappropriate pathology and radiology testing. In one meta-analysis mean rates of over- and under-utilization of laboratory testing were reported to be 20.6% and 44.8% respectively (5). Radiological imaging is often an over-utilised modality in patient care that not only adds to the cost but also exposes patients to unnecessary radiation. The American College of Radiology (ACR) published appropriateness criteria in 2006 (6). In a subsequent study Andre et al demonstrated that there is low utilization of the ACR appropriateness criteria by clinicians when ordering imaging studies for their patients (7).

Hopefully, this article will generate interest in this domain and there will be more studies to look at other areas of inappropriate patient care in our hospitals.


1. Duckett SJ, Breadon P and Romanes D. Identifying and acting on potentially inappropriate care. Med J Aust 2015; 203: 183e.1 - 183e.6

2. Ibrahim JE. It is not appropriate to dismiss inappropriate care. MJA 2015; 203(4): 161-162

3. Scott IA, Harden H and Coory M. What are appropriate rates of invasive procedures following acute myocardial infarction? A systematic review. MJA 2001; 174(3): 130-136

4. Juillerat P et al. EPAGE II. Presentation of methodology, general results and analysis of complications ... Endoscopy 2009; 41: 240 – 246

5. Zhi M et al. The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis. PLoS ONE 2013; 8(11): e78962

6. Bettmann M. The ACR appropriateness criteria: view from the committee chair. J Am Coll Radiol 2006; 3: 510–512

7. Andre B, et al. Do Clinicians Use the American College of Radiology Appropriateness Criteria in the Management of Their Patients? American Journal of Roentgenology. 2009; 192: 1581-1585

Competing Interests: No relevant disclosures

Assoc Prof Sanjay Sharma
Ballarat Health Services

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