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Health services administration

Health services administration Letters 20 August 2018 Free

Potential solutions to improve the governance of multicentre health services research

To the Editor: As Clay-Williams and colleagues,1 we have also experienced frustration at the time-consuming, expensive2 and protracted processes required as a prerequisite before undertaking research involving identified patient data across Australia. Ironically, in the case of clinical quality registries, we collect data designed to measure quality of care so that patients may benefit from improved clinical processes. Yet, the system conspires to delay and undermine these efforts. There are lessons we have learned in developing clinical quality registries that deal with some governance issues identified by Clay-Williams and colleagues. They describe developing a legal agreement, which 21% of hospitals refused to accept. The Southern Eastern Border States (SEBS) Committee was developed with representatives of health departments from Victoria, New South Wales, Queensland and South Australia to streamline and prevent duplication of legal agreements.3 We worked with a SEBS Committee representative to develop special clauses and conditions to include in the Medicines Australia Clinical Trials Research Agreement schedule, subsequently endorsed by the SEBS Committee. Participating sites, both public and private, recognise and routinely accept this agreement. This same committee, or one with a similar construct, could determine nationally whether research is low risk to address the confused and contradictory advice given by ethics committees. We agree that standardisation of forms and processes is required — participating sites should not be permitted to introduce their own forms, causing confusion to researchers and introducing additional delays. A national information portal and repository for protocol amendments which governance officers can access to review or approve changes would be welcomed. However, while Clay-Williams and colleagues recommend that there should be no requirement for principal investigators to be employees of the participating site, we believe that for clinical quality registries, having a local principal investigator provides a vital link between researchers and local staff. As previously suggested,4 limits should apply on an acceptable time period to provide a definitive determination on study conduct within an institution, as occurs in Europe with clinical trials.5 It is unacceptable that this process lasts more than 60 days. As researchers usually have no capacity to have an impact on institutional authorisation processes, greater accountability should vest with governance offices. The current costly and dysfunctional system is stifling research in Australia.

Sue M Evans · John R Zalcberg · Ri Scarborough

Health services administration Letters 2 July 2018 Free

Selecting medical students: we need to assess more than academic excellence

To the Editor: Reading the article on the task of selecting candidates for medical school,1 I recalled my own trajectory into the profession. I was interviewed by a surgeon, who was the sole interviewer, our interaction being one of genteel conversation. My peers at the time had a similar interchange with the university officials. Uniformly, we have all proceeded to remain in medicine. Our careers have lasted. One has to wonder whether a selection process that is more time consuming is actually better than the above straightforward approach. Considering personality type, there will be a wide spread of introverts and extroverts. Academically adept and generally bright, the hopefuls can perform on the day to leap over any clever tests for entrance. Moreover, the profession has niches for all of them. The introvert can quietly tend towards microbiology, while the extrovert might heartily choose to be a surgeon. Like politics, the profession needs representatives from different areas of society. We should not aim to standardise too much. There will be nations today where entry into medicine is still standardised with reference to social status. If we recruit only the well-to-do youngsters, we will not have the level of understanding that can be brought into the profession from those of humbler backgrounds. Someone from a lower economic stratum will understand the community to which they wish to return after qualifying as a doctor. I have first-hand experience of observing such a course of career in my peers. It cannot be forgotten that the aspirants keen to join medicine are very young people whose personalities have yet to ripen through living. If they can pass tough exams, then they have an admirable trait as embryonic personalities. They can focus and work with diligence. They also hold an ambition to become doctors. If they can apply themselves and do not have any overt oddities of personality, they should be given a chance to become doctors. This has been a time-tested method in medical schools — in a world that needs more doctors than ever — and I fail to be convinced that finer filters on the path into medicine will be worthwhile.

Jagdeep Singh Gandhi

Letter to the Editor1
Women's health Letters 18 June 2018 Free

Population attributable fractions of perinatal outcomes for nulliparous women associated with overweight and obesity, 1990–2014

To the Editor:We congratulate Cheney and colleagues1 for throwing light on the contributions of overweight and obesity on adverse birth outcomes by analysing data from a teaching hospital in central Sydney.1 Around 16% of the women presenting between 2010 and 2014 were overweight, while 7% were obese. Furthermore, despite obesity being an important risk factor for adverse pregnancy outcomes, their study showed a lack of recording of body mass index (BMI) in patients’ records. Adverse pregnancy outcomes are more common among Indigenous Australian women than non-Indigenous women;2 obesity levels are high in pre-conception and in pregnancy, and the subsequent adverse impact on increased metabolic health in offspring is likely contributing to early onset of diabetes and chronic disease in Indigenous Australians. Hence, we want to extend the debate to report on what is happening in primary health care (PHC) settings for Indigenous women. We have analysed continuous quality improvement data from audits of adherence to evidence-based guidelines for maternal care in 65 Indigenous PHC centres (1091 patient records) across Australia during 2012–2014.3 The majority of women at most PHC centres had the first trimester weight recorded (mean, 90%; range, 60–100%), but there was wide variation in recording of BMI (mean, ∼ 60%; range, 0–100%) (Box). This indicates that most barriers to BMI recording are more to do with clinicians’ understanding of the value of and ability to calculate BMI than around women’s willingness to be weighed. For women with an abnormal BMI (mean, ∼ 30%; range, 0–100%), there was wide variation in documented BMI management plans (mean, ∼ 40%; range, 0–100%). Dealing with these generally low levels of recording and wide variation in recording between PHC centres is a vital early step in limiting the contribution of obesity to adverse pregnancy outcomes and improving long term health outcomes for the mother and baby. Women attending PHCs that had participated in continuous quality improvement activities were more likely to receive recommended pregnancy care related to screening and brief interventions for modifiable lifestyle-related risk factors, such as obesity.4,5 These findings support the incorporation of continuous quality improvement activities into the delivery of maternal care. Box – Record of scheduled maternal care services received by Indigenous women at Indigenous primary health care centres, 2012–2014* BMI = body mass index. * More information on how to interpret box plots is available in Gibson-Helm et al,3 page 21.

Jodie Bailie · Jacqueline A Boyle · Ross S Bailie

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