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Acting on potentially inappropriate care

Stephen J Duckett, Peter Breadon and Danielle Romanes
Med J Aust 2016; 204 (2): 72. || doi: 10.5694/mja15.01241
Published online: 1 February 2016

Measuring inappropriate care should rely on evidence available at the time, with anomalous practices evaluated by clinical panels

Our recent MJA article1 and accompanying report2 set out a model for harnessing clinical expertise and government resources to address the issue of inappropriate care.

This model involves four steps. First, a credible, independent body would review clinical evidence to identify potentially inappropriate treatments. Second, the same body would monitor use of those treatments. Hospitals providing the treatments more frequently than the national average rate would be advised of that fact. Third, if a hospital’s abnormal practice persisted, they would face an external clinical review in which they could justify their practice to peers. Finally, if the reviewers found this justification unsatisfactory, only then might there be financial consequences.

It is hard to see how this cautious and clinician-led model is punitive, as Sherlock labels it.3 We do not recommend taking potentially inappropriate treatment options away from clinicians. Instead, we recommend monitoring their use and initiating clinician-led reviews of unusual practice patterns, recognising that even do-not-do treatments may be justified in some circumstances.

Our model recognises that health care is dynamic and the evidence often changes, so that procedures seen as inappropriate in one year could be regarded as good practice the next. We took care in our study to ensure that we were only analysing treatment choices that were inconsistent with the prevailing evidence at the time our data were collected. Evidence that was outdated or published after our study year was not taken into account. Therefore, we disagree with the critiques of our findings by Sherlock3 and Clark.4

Clark4 questions our identification of vertebroplasty for osteoporotic spinal fractures as potentially inappropriate, but the current NICE guidance (https://www.nice.org.uk/guidance/ta279) and forthcoming trial that they refer to were not available during our study year. Although 2003 NICE guidance (https://www.nice.org.uk/guidance/ipg12) supporting use of vertebroplasty was available during our study year, it had been contradicted by the more recent landmark trials published in 2009.5,6 This change in prevailing evidence was reflected in the subsequent recommendation by the Medical Services Advisory Committee (MSAC) to defund the procedure.7

Sherlock likewise refers to evidence that was not current during our study year. MSAC report 1054.18 was published too late to influence clinicians’ treatment choices when our data were collected, while MSAC report 10549 recommendation of time-limited support for certain conditions requiring hyperbaric oxygen treatment had lapsed well before our study year.

We accept that the 4500 admissions that we identified did not involve 4500 people; unfortunately, our data did not allow us to identify the number of individuals treated. Our dataset also did not include Medicare Benefits Schedule item numbers. We therefore relied on the International Classification of Diseases 10th revision (ICD-10)-coded diagnosis and Australian Classification of Health Interventions procedure codes available in the hospital discharge abstract.

We were conservative in our approach to identifying potentially inappropriate care, excluding all cases where a patient had a diagnosis that was an indication for the treatment. To use Sherlock’s example, a patient with a primary diagnosis of “waiting for residential care” who also had a diagnosis of diabetic ulcers would not have been counted as a do-not-do patient in our study, as they had a comorbidity (diabetic ulcers) that may have legitimated hyperbaric oxygen treatment.

Despite our exclusions, we remained wary of coding errors, and designed our analysis and recommendations to take them into account. We excluded hospitals with very low rates of relevant procedures or patients. As a result, an isolated coding error could not result in an above average rate of questionable treatments. If numerous coding errors did lead to a false positive, these would have been uncovered during our proposed clinical reviews. If the result of adopting our model is more accurate coding, in addition to appropriate care, that is an added benefit.

We do not believe that the criticisms from Sherlock and Clark invalidate our findings, but we do welcome debate about our approach. It shows that there is a strong interest in making sure that measurement of practice variation and potentially ineffective treatment is robust and clinically meaningful.

We have proposed a practical method for moving from talking about the issue to acting on it. We do so in a way that involves significant clinical input, as we acknowledge that overcoming the problem of inappropriate clinical variation requires strong clinical leadership.10 Doing nothing is not an option. Provision of clinically inappropriate care incurs a cost to both patients and the health system. Not acting on our findings means that people will suffer and we waste resources.


Provenance: Commissioned; not externally peer reviewed.

  • Stephen J Duckett
  • Peter Breadon
  • Danielle Romanes

  • Grattan Institute, Melbourne, VIC


Competing interests:

No relevant disclosures.

  • 1. Duckett S, Breadon P, Romanes D. Identifying and acting on potentially inappropriate care. Med J Aust 2015; 203: 183e.1-183e.6. <MJA full text>
  • 2. Duckett S, Breadon P, Romanes D, et al. Questionable care: avoiding ineffective treatment. Melbourne: Grattan Institute, 2015. http://grattan.edu.au/wp-content/uploads/2015/08/828-Questionable-Care3.pdf (accessed Dec 2015).
  • 3. Sherlock S. Inappropriate care in medicine. Med J Aust 2016; 204: 70-70.e1.
  • 4. Clark WA. Vertebroplasty is not a do-not-do treatment. Med J Aust 2016; 204: 71-71.e1.
  • 5. 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.
  • 6. Buchbinder R, Osboren RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009; 361: 557-568.
  • 7. Doidge J, Merlin T, Liufu Z, et al. Review of interim funded service: vertebroplasty and new review of kyphoplasty. MSAC application 27.1. Canberra: Commonwealth of Australia, 2011. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/27.1-public (accessed Nov 2015).
  • 8. Medical Services Advisory Committee. Review of interim funded service: hyperbaric oxygen therapy (HBOT) for the treatment of chronic non-diabetic wounds and non-neurological soft tissue radiation injuries. MSAC application 1054.1. Canberra: Commonwealth of Australia. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/1054.1-public (accessed Dec 2015)
  • 9. Medical Services Advisory Committee. Hyperbaric oxygen therapy for the treatment of non-healing, refractory wounds in non-diabetic patients and refractory soft tissue radiation injuries. MSAC application 1054. Canberra: Commonwealth of Australia, 2003. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/1054-public (accessed Dec 2015)
  • 10. Scott IA, Duckett SJ. In search of professional consensus in defining and reducing low-value care. Med J Aust 2015; 203: 179-181. <MJA full text>

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access_time 05:42, 2 February 2016
David R Smart

Duckett, Breadon and Romanes and colleagues have unfortunately made a serious error of fact in their reply to Sherlock. Because of their error, and the issues referred to by Sherlock, the paper "Acting on potentially inappropriate care" is flawed. Their statement ".....MSAC report 1054 recommendation of time-limited support for certain conditions requiring hyperbaric oxygen treatment had lapsed well before our study year", is completely inaccurate. Their study data collection occurred in 2010-11. Following the MSAC 1054 report, two conditions were funded for hyperbaric oxygen treatment (HBOT) under a Ministerial 3C determination: Non-diabetic problem wounds, and soft-tissue radiation injury. The Medicare funding for non-diabetic problem wounds was withdrawn on 1st November 2012 following MSAC 1054.1 report. Hence the time-limited Federal Government support for HBOT had not lapsed at the time Duckett and colleagues collected their data. Duckett et al's methodology therefore erroneously defined as a do-not-do treatment, a condition which was fully funded by Medicare. This fundamental error completely invalidates their data.

Competing Interests: I was a clinical panel member for the MSAC 1054 and 1054.1 reviews

Assoc Prof David R Smart
Royal Hobart Hospital Tasmania

access_time 10:44, 5 February 2016
Stephen Duckett

There is no error of fact in our paper. In 2003, the MSAC noted inadequate evidence to support use of HBOT for refractory soft-tissue injuries and non-diabetic refractory wounds (though we note Professor Smart provided a dissenting view at the time), but recommended a further three years of funding in anticipation of forthcoming research. These three years had elapsed well before our data period of 2010-11. MSAC reviewed the issue in 2010-11 and in its report MSAC 1054.1 again found insufficient evidence to support public funding for HBOT for the relevant specific conditions.

In our original paper, we examined five treatments for specific conditions, many of which attracted public funding at the time. The issue we were looking at was whether there was evidence that those treatments should be used in those conditions, not whether there was funding for them. HBOT for the listed indications fell firmly into the former category, and was described as a "do not do" on that basis.

Competing Interests: No relevant disclosures

Dr Stephen Duckett
Grattan Institute

access_time 12:18, 8 February 2016
Glen Campbell Hawkins

The statement that Duckett and colleagues have made regarding Hyperbaric Oxygen therapy for Refractory soft tissue injuries is at odds with the statement made in MSAC report 1054.1 from which I quote:

"From these results, HBOT as an adjunct to conventional treatment appears to provide significantly greater clinical benefit to patients, compared to conventional treatment without HBOT, for the treatment of non-neurological soft tissue radiation injuries."
MSAC 1054.1 Pg 117

In the Public Summary Document for MSAC 1054.1, which discussed the appropriateness of public funding it stated:

"After considering the strength of the available evidence in relation to the safety, effectiveness and cost-effectiveness of Hyperbaric Oxygen Therapy for the treatment of localised non-neurological soft tissue radiation injuries (that have not responded to usual treatments), excluding lymphoedema following breast cancer, MSAC supports continued public funding for HBOT for this indication."
Public Summary Document for MSAC 1054.1 Item 15 (Pg 16)

As both these statements contradict the above statement from Duckett et al in their report, I am concerned that other statements that they have made, particularly those that have been refuted so clearly by Dr Sherlock and others, also do not stand up to closer scrutiny when the source material contradicts their own "findings".

Competing Interests: Chief Medical Officer for Hyperbaric Health

Dr Glen Campbell Hawkins
Hyperbaric Health, University of NSW

access_time 07:34, 9 February 2016
David R Smart

It is unfortunate that Duckett, Romanes and Breadon have chosen to deny their errors without making appropriate checks. There are additional factual errors in their reply to my post.

(1) My dissenting report was published in response to MSAC 1054.1 in 2011 (not 2003 and MSAC 1054, as stated by the authors).

Although MSAC 1054 committee deliberations were completed in May 2003, but the actual report was not published until November 2004 (recorded on page 2 of the report).

(2) Interim funding was provided for hyperbaric oxygen treatment for soft tissue radiation injury (STRI) and non-diabetic wounds (NDW) from November 2004 until November 2012 (Not 3 years as asserted by Duckett et al).

(3) To assert twice that funding was discontinued after 3 years misrepresents the facts. Medicare statistics from 2004-2012, demonstrate clearly that item number 13015 had services reimbursed to patients for the treatment of STRI and NDW that fully spanned Duckett et al's 2010-11 study period.

On that basis, it appears that Duckett et al, decided, as non-clinicians, that the conditions STRI and NDW were do-not-do treatments, well before the Federal Government's own system (MSAC) had undertaken its review of evidence.

This sets a serious and dangerous precedent, where Duckett et al decided to label existing funded conditions (or procedures) as "do-not-do", before the clinical evidence was evaluated.

Because the conditions were funded by Medicare for HBO treatment, Duckett et al's study of HBO treatment has collected data which they have wrongly classified.

This is a fundamental error at the data collection point which invalidates their whole paper. Given that HBO treatments made up 79% of their data, any conclusions of the paper (or the Grattan report) cannot be sustained.

(4) Soft Tissue Radiation injury remains fully funded following the MSAC 1054.1 review. Duckett et al have repeatedly stated that soft tissue radiation injury (including radionecrosis - box 2 page 183e.3 MJA) is a do-not-do treatment with HBOT. This is contrary to MSAC's findings (and inaccurately misrepresents the authors' own references). The evidence for STRI was validated and funding confirmed (MSAC 1054.1). At no stage was funding withdrawn for STRI as asserted by the authors, and MSAC has confirmed the evidence.

Perhaps it is a Machiavellian slip that Duckett's reference 19 in the MJA article erroneously left out the words "soft tissue radiation injury". The authors have failed to accurately cite and interpret the literature they have referenced in making their case.


Competing Interests: I was a clinical panel member for the MSAC 1054 and 1054.1 reviews

Assoc Prof David R Smart
Royal Hobart Hospital, Tasmania

access_time 12:26, 16 February 2016
Stephen Duckett

Without getting into an infinite regression, we would reiterate that whether funding was available or not for a procedure was not one of the issues we considered in our original paper. We looked at whether evidence was available to justify use. We used the five conditions in our study as examples and proposed a way forward for doing this sort of analysis on a routine basis. In our full paper we proposed that the Australian Commission on Safety and Quality in Health Care should have this role. Whether the Commission (if it takes on this role) would agree with us or your correspondents on the clinical value of HBOT in the circumstances we examined would hopefully depend on the strength of the available evidence at the time.

Competing Interests: No relevant disclosures

Dr Stephen Duckett
Grattan Institute

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