Health care variation: the next challenge for clinical colleges

Unwarranted variation in health care requires action from all players in health — including clinical colleges

Marked variations in the use of 18 health care services, such as hospitalisations for chronic diseases and surgical procedures, were reported in the Second Australian atlas of healthcare variation (the second Atlas), recently published by the Australian Commission on Safety and Quality in Health Care (the Commission).1 The amount of variation seen is unlikely to be explained by differences in patient needs, and so indicates opportunities for delivering more effective patient care and getting better outcomes for individuals and for the community.2

The second Atlas includes data analyses conducted by the Australian Institute of Health and Welfare, and 49 recommendations for action formulated by the Commission. The recommendations are designed to help clinicians and health system managers turn these improvement opportunities into reality. They focus on improving appropriateness of care and are targeted at many groups, including Local Hospital Networks, Primary Health Networks, Commonwealth, state and territory health departments, the Medicare Benefits Schedule Review Taskforce, and the Commission itself. The recommendations recognise that effective change to the way services are provided, or improved access to certain types of services, requires commitment and collaboration from funders and health service providers. But many of the actions to improve care or to stimulate change in the broader health system have implications for what happens in the clinical encounter between doctor and patient. This goes beyond a focus on the immediate clinical problem — many of the conditions and interventions featured in both the first and second Atlases are influenced by common underlying factors, such as obesity, smoking and diet, that have a significant impact on the need for health care.1,2

For example, the second Atlas found the rate of knee replacement surgery varied by up to fourfold according to where patients live in Australia. Part of this variation is very likely due to differences in rates of obesity. Pain or mobility problems caused by osteoarthritis are the reason for 98% of knee replacements in Australia.3 The risk of osteoarthritis of the knee for overweight people is double the risk for people of normal weight; in obese people, it is four times as high.4 An estimated 53% of total knee replacements in Australia are due to obesity,4 and Australia’s relatively high rate of knee replacement surgery among Organisation for Economic Co-operation and Development countries mirrors its similarly high ranking in obesity rates.5

Although knee replacement has undeniable benefits in suitable patients, avoiding surgery if more conservative measures are appropriate is better for the patient — and for the health system as a whole. For people with knee osteoarthritis, guidelines recommend use of a range of pharmacological and non-pharmacological approaches before surgery, including weight loss, physiotherapy, and use of medicines to relieve pain and inflammation.6,7 These strategies are effective. For example, even a 5% weight loss can improve symptoms for overweight people with symptomatic osteoarthritis of the knee.8 However, guidelines relating to osteoarthritis have not been fully implemented in Australia, and conservative treatments remain underused.9

The second Atlas maps care for many conditions and surgical interventions to which lifestyle factors such as obesity contribute; these include osteoarthritis, diabetes, heart failure, cardiovascular disease, atrial fibrillation, and gallstones, which are a risk factor for cholecystectomy. This raises the question of who should take responsibility for reducing obesity levels. Strategies to modify the environment and to shape the population’s lifestyle habits have dominated the conversation about obesity, but all clinicians — and not only general practitioners — have a part to play. Small actions by individuals, when undertaken on a large scale, are a powerful force for change. The second Atlas notes the importance of including strategies to manage obesity as options in health care decision making. If all clinicians routinely measured markers of obesity, the extent to which this is driving health care use and costs would become much more apparent. To prompt this action, the second Atlas recommends that government health departments promote routine measurement and recording of obesity markers such as body mass index or waist circumference for all people who attend primary care and outpatients, or who are admitted to a health service for care.

Colleges are well placed to lead such a change and have already taken initial steps. Some individual colleges have resources for their members — for example, the Royal Australian College of General Practitioners provides guidance to members on the range of evidence-based options available for helping patients lose weight.10 But much more needs to be done if the management of obesity is to be accorded the prominence it deserves. In November 2016, the Council of Presidents of Medical Colleges held a national health summit on obesity and released a consensus statement for action.11 The statement recognised the importance of both prevention and treatment of obesity and the need for multiple organisations and government to work together to tackle these challenges. It concluded by noting that “the challenge now for all of us is TO DO!”.11

The second Atlas recommends that the Council of Presidents of Medical Colleges progress its work on obesity by identifying actions that can be taken by professional colleges and societies to improve the prevention and management of obesity. This work could include:

• a published review of current curricula requirements and available skills training on obesity prevention and management across all colleges;

• use of this information to help identify what needs to be done to develop a world’s best practice core curriculum that could be used in registrar and continuing professional development (CPD) training for all colleges;

• development of generic skills training to equip doctors to discuss weight management with patients. This training could be supplemented by college-specific modules that focus on ways to discuss and manage obesity as part of condition-specific consultations;

• a practical resources kit suitable for use with patients; and

• ongoing monitoring across all colleges of the extent of uptake of training on obesity so that an assessment of any changes needed to improve uptake of training can be made.

Australia spends substantial amounts of money on “sick care”, but relatively little on “health care”. For example, an estimated $3.8 billion was spent in Australia on health care directly related to obesity in 2011–12.12 While reducing obesity levels needs a mix of approaches, interventions delivered or prompted by clinicians are an important part of this mix. Reducing obesity is only one preventive activity in which clinicians — and therefore their relevant medical colleges — could make greater efforts. Impressive gains have been made in reducing smoking rates in Australia, but certain groups still have substantially higher rates than the Australian average of 15%: Aboriginal and Torres Strait Islander people (41%),13 people in the highest quintile of socio-economic disadvantage (21%), and those living in regional or remote areas (21%).14

Preventive activities such as reducing obesity and smoking rates, and improving diet and exercise, have been seen as the responsibility of public health organisations and GPs alone for too long. This vital primary and secondary prevention work needs to move into the domain of all clinicians. Several mechanisms are in place for colleges to promote preventive activities, such as training curricula and CPD programs. For example, practice audits within CPD programs could include questions asking practitioners about the percentages of their patients for whom they have calculated body mass index, who are overweight, and who have received counselling about losing weight.

The second Atlas highlights many other areas in which colleges could make a significant contribution by providing resources and training to members, including:

• improving cultural competency for working with Aboriginal and Torres Strait Islander patients;

• sharing information with other clinicians to better coordinate care by patients’ health care teams; and

• working with patients, families and carers as partners in care, where patients are supported to maximise their knowledge, skills and confidence to manage their health — this includes matching the delivery of health information to patients’ levels of health literacy.

An important philosophical shift needs to be led by the colleges. That is, a clinician’s responsibility is not only to the patient before them, and not only in their specialty, but to all patients. This means making management choices that maximise the effectiveness of health resources. Drawing a sensible line about when to opt for more conservative treatment, resisting investigations with little chance of producing useful findings, and addressing risk factors to prevent conditions worsening or developing are some of the ways in which clinicians can reduce unwarranted variation in health care while also making better use of health dollars. These actions are consistent with their code of conduct.15

Creating guidelines and encouraging best practice through training and CPD programs are the first steps for colleges in overcoming unwarranted variation. Aiming higher by supporting their members to maximise the effectiveness of the health system as a whole is their next challenge.