Health services administration

To the Editor: Intensive care is a finite and costly resource with nine beds per 100 000 population in Australia and at a cost of $4000 per bed-day. From 1999, the demand for intensive care unit (ICU) beds has increased at an average rate of 2.5% annually.1,2 Faced with increased demand and capacity restraints, fiscal sustainability is dependent on efficient use of limited ICU resources. ICU bed availability varies significantly across countries and creates a threshold for clinicians to admit patients.3 The availability of beds may be influenced by the number of patients well enough for ward discharge but who are exit blocked. ICU access block is a significant safety concern for critically ill patients, and ICU exit block (the inability to discharge a patient who is medically fit for discharge) may contribute significantly to ICU access block.4,5 Using a single-day point prevalence study, we obtained an estimate for ICU exit block in 39 Australian and ten New Zealand adult ICUs in 2014. Across all sites, 13% (median value of exit block across the sample hospitals, 8.1%; interquartile range, 0–23%) of patients in the ICU on the study day were awaiting a ward bed. Patients in Australian ICUs were twice as likely to be exit blocked compared with patients in New Zealand ICUs (14.9% v 7.6%). Hospital and ICU size and location (rural v metropolitan) did not influence levels of exit block, but ICUs with > 80% occupancy had higher levels of exit block (Box). Our results were similar to those of the 2007–14 Australian Council on Healthcare Standards clinical indicator report, which found that about 25% of ICU discharges were delayed for more than 6 hours.5 Using an ICU bed for a patient who no longer needs it represents an inefficient use of resources and risks creating delays in admitting other acutely unwell patients. In the emergency department setting, we have seen the 4-hour rule improve hospital access and outcomes by prioritising transfer of emergency department patients to ward beds. Monitoring ICU access and exit block provides a comparable metric for understanding the effects of prohibiting ICU patient flow and for determining how to safely and efficiently allocate limited resources for critically ill patients. Box – Intensive care unit (ICU) bed occupancy and exit block Bed occupancy No. of ICUs* Median percentage of patients experiencing exit block (IQR) 0–50% 6 0 (0–28.6%) 51–80% 20 0 (0–10.8%) 81–100% 21 13.0% (5.5–25%) IQR = interquartile range. * Two sites did not provide bed occupancy rates so were not included in our analysis.

Matthew H Anstey · Kelly Thompson · Ian Seppelt

In reply

Leonard Kritharides · Vincent Chow · Tim JR Lambert

To the Editor: We read with interest the recent study by Freed and Allen on the cost to patients of consulting a private specialist physician.1 Although not the main focus of the study, we were intrigued by the disproportionately low bulk-billing rates by physicians in Western Australia. This was highlighted in the local media,2 with an implication that WA physicians are out of step with interstate colleagues on billing practices. We acknowledge there was no such assertion in the article by Freed and Allen.1 The study findings are based on Medicare data supplied by the Commonwealth Department of Human Services.1 However, the data do not appear to differentiate between Medicare billing in private physicians’ rooms (which is the intended target of the study) or elsewhere. Hence, the bulk-billing findings may be confounded by occasions of Medicare billing occurring in outpatient clinics run by public hospitals. Public hospital services are usually funded by state governments. Nevertheless, Commonwealth (ie, Medicare) funded clinics are permitted under an interpretation of the Health Insurance Act 1973 that allows private services to be rendered by specialists within a public hospital.3 Anyone with a Medicare card is eligible to be considered a “private patient”. If bulk-billed, the patient will not suffer any financial disadvantage — or notice any difference — compared with attending an ordinary state government funded clinic. In most cases, revenue from Medicare is not retained by the specialist, but donated to the hospital to defray clinic costs.4 This model permits the creation of new fee-free hospital outpatient services that would otherwise be unsustainable within the existing state funding. In view of the large number of outpatient visits to public hospitals, there could be an inflation of statewide physician bulk-billing rates where Medicare funded hospital clinics are widespread. In our experience, such clinics are rare or non-existent in WA. It would be interesting to reappraise bulk-billing rates if billing episodes occurring at public hospitals could be excluded. We suspect that bulk-billing rates occurring entirely within private specialist rooms are not significantly different between jurisdictions.

Gregory SY Ong · Senq J Lee · Dejan Radeski

To the Editor: The demand for human leukocyte antigen (HLA) typing in the diagnostic work-up of coeliac disease (CD) in Australia has driven a 14-fold rise in testing since 2003 (Medicare Benefits Schedule data, item 71151). Although HLA typing offers limited specificity for CD, its clinical utility results from its exceptional negative predictive value (> 99%) when the specific HLA susceptibility genotypes are not detected.1 Unlike traditional tests for CD, HLA typing results are informative even when the patient is following a gluten free diet. While the accuracy of HLA typing in CD has not been reported, HLA test results are assumed by clinicians to be definitive. Our findings challenge this view. Discrepancies between several patients’ clinical diagnosis of CD and their negative HLA-DQ2 and -DQ8 typing results in AJD’s practice led to repeat HLA testing with another laboratory. The subsequent reporting of a genotype consistent with CD prompted a clinical audit (2013–2016). Of 211 patients with HLA typing results, nine had been coperformed by two separate laboratories (laboratories 1 and 2), either deliberately or inadvertently. Of these nine patients, six returned conflicting results. An additional DNA sample from all six patients was sent for HLA genotyping by a reference laboratory, where genetic susceptibility for CD was confirmed in five patients (Box). Laboratories 1 and 2 differed in the detection of risk alleles and in the interpretation of or reporting of the results in all six cases. Laboratory 2 identified an at-risk allele in only two of the six patients, and of the four patients with a reported negative genotype, two were subsequently confirmed to have definite CD. These preliminary findings raise serious concerns about CD HLA testing errors that adversely affect patient care. Although identified in Queensland, these laboratories routinely outsource their HLA typing to laboratories in New South Wales and Victoria, indicating that several Australian states are involved. We are particularly concerned about laboratories new to HLA testing or laboratories that are not participating in stringent quality assessment programs as the sourced reference laboratory does. Therefore, we suggest that an assessment of the performance and quality control measures of all laboratories offering HLA typing is urgently needed. Consistent adoption of evidence-based guidelines that describe optimal HLA testing and reporting1 should form part of the solution. Box – Human leukocyte antigen (HLA) typing results from three laboratories† Patient Laboratory 1 Laboratory 2 Reference laboratory Confirmed CD “Consistent with DQ2 phenotype; susceptible for CD” Genotype not supplied; “Not susceptible for CD” HLA-DQ2.2/2.5; susceptible to CD Incorrect Confirmed CD “Consistent with DQ2 phenotype; susceptible for CD” Genotype not supplied; “Not susceptible for CD” HLA-DQ2.2; susceptible to CD Incorrect CD excluded “Consistent with DQ2 phenotype; susceptible for CD” Genotype not supplied; “Not susceptible for CD” HLA-DQ2.2; susceptible to CD Incorrect CD not excluded; on GFD “Consistent with DQ8 phenotype; susceptible for CD” Genotype not supplied; “Not susceptible for CD” No susceptibility to CD detected Incorrect Normal CD serology “DQ2 and DQ8 not identified; no genotype susceptibility for CD” “DQA1*0505 has been detected; small percentage susceptible to CD” DQA1*05 (HLA-DQ7); low risk susceptibility to CD Incorrect CD excluded “DQ2 and DQ8 not identified; no genotype susceptibility for CD” “DQA1*0505 has been detected; small percentage susceptible to CD” DQA1*05 (HLA-DQ7); low risk susceptibility to CD Incorrect CD = coeliac disease. GFD = gluten free diet. ND = not detected. † The reference laboratory was in the Victorian Transplantation and Immunogenetics Service in Melbourne. In addition to the incorrect typing results, laboratory 2 failed to report the specific alleles detected and laboratory 1 failed to distinguish between HLA-DQ2.5 and DQ2.2.

A James M Daveson · Michael Varney · Kate E Jackson · Jason A Tye-Din

Editor’s note: The Lancet recently published an important Australian randomised controlled trial of robotic and open prostatectomy. We publish the following non-commissioned correspondence by Hutchison and colleagues together with an invited response from the corresponding author of the trial, Robert Gardiner, because of the relevance of the debate to Australian health care. To the Editor: Robotic prostatectomy took off quickly, despite the cost. In Australia, most prostatectomies are now done with a robot that costs almost $10 000 in capital and maintenance per procedure, or between $442 and $3548 more than an open prostatectomy.1 The robotic option was meant to reduce side effects relating to impotence and incontinence; however, preliminary findings from the world’s first randomised controlled trial suggest that this is not the case.2 Uptake of innovative surgery tends to outpace evidence because it is hard to design and run randomised studies. In addition, placebo surgery is rare and controversial, and recruitment is challenging, as surgeons and patients often prefer one option. Trial results may also be difficult to interpret: if the same surgeon performs both operations, they may be better at one; or if different surgeons operate, one may be superior.3 Australia is not immune to these challenges, despite local initiatives to improve quality of care4 and evaluate the benefits of the robotic procedure.5 The industry understands this. Intuitive Surgical aggressively marketed its robot while the jury was still out on its comparative benefits. Celebrity stories have also driven demand; for instance, radio personality Alan Jones has been an outspoken advocate.6 But even when evidence commends a surgical innovation, introducing it to the public health care system may create or exacerbate inequity. Suppose that the robot, or some successor, eventually proves superior to alternatives. Expensive equipment and difficult procedures require high patient throughput to justify the costs and maintain surgeons’ skills, so they tend to be concentrated in the biggest, busiest hospitals. Therefore, patients in regional areas are often expected to travel for treatment, with little or no financial support; and the barrier is even higher for people who do not have the social and economic resources to get themselves to a big city hospital.7 We should resist the hype of a new technology and wait for good evidence before expending scarce health care dollars. This will sometimes mean lagging behind other countries and saying no to patients. However, it will also mean safeguarding patients and the public purse from innovations that turn out to be no better, or maybe worse, than existing options. Moreover, when a new technology is introduced, we should also fund the supports that people need to access it.

Katrina Hutchison · Drew Carter · Jane Johnson

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Rosalie Schultz