Health services administration

To change practice, we should move beyond trial-based efficacy to real-world effectivenessMeaningful health care reform requires robust evidence about which interventions work best for whom and under what circumstances. The Institute of Medicine in the United States has estimated that less than 50% of current treatments are supported by evidence and 30% of health care expenditure reflects care that is of uncertain value.1 In studies ...

Ian A Scott FRACP, MHA, MEd

Public reporting of hospital performance is welcome, but we need to understand the limitations of the data and report the most meaningful outcomes.

Leon J Worth MB BS, FRACP, PhD · Ann L Bull PhD · Michael J Richards MB BS, FRACP, MD

To the Editor: In a recent article,1 Elkin and colleagues concluded that, compared with Australian-trained doctors (ATDs), international medical graduates (IMGs) posed a greater risk of attracting complaints to medical boards. However, we think the conclusion is not supported by the data, and might have been compromised by the analytical methods used. Box of the research article1 shows that IMGs accounted for 37% of the total ...

Nguyen D Nguyen · Tran V Nguyen

To the Editor: The article by Elkin and colleagues has certainly reheated the long-simmering debate about bringing highly trained international medical practitioners from other countries to provide health care in Australia. Yet, it does not discuss the clinical and cultural acclimatisation they need. There are many moral and social issues associated with condemning an IMG without helping them to adapt to their locality. The study ...

Shailja Chaturvedi

To the Editor: In the article by Elkin and colleagues,1 the conclusions drawn from the data analysed do not appear to be adequately supported. It should be noted that only 30% of complaints against doctors had a final hearing, and the risk of adverse findings (ie, where the doctor was found to be guilty) was not analysed by country of origin. Although doctors from certain ...

Snehal P Akre · Amit C Achhra

To the Editor: While using medical board data for research purposes is very welcome, I have some reservations about ethical aspects of the study by Elkin and colleagues.1 Prospective ethics review of human research is intended to protect participants from foreseeable and avoidable harm. I suggest that, in this instance, avoidable harm has resulted, through generalised adverse and possibly unfair publicity about particular groups of ...

Kerry J Breen

In reply: Nguyen and Nguyen question our finding that international medical graduates (IMGs) are at higher risk of attracting complaints than Australian-trained doctors (ATDs),1 based on recalculations using the descriptive statistics we reported. They infer, from the fact that IMGs accounted for 37% of doctors and 30% of total complaints, that IMGs were at lower risk of complaints. Comparisons of simple proportions as above mislead for ...

David M Studdert · Matthew J Spittal · Katie Elkin

Are state selection systems for internship positions discriminatory and unconstitutional?

Dev A S Kevat LLB(Hons), MPH · Fiona J Lander MB BS(Hons), LLB(Hons)

To the Editor: Caplan et al1 include in their meta-analysis a trial by Mather et al that compared home care with intensive care management of patients with acute myocardial infarction (AMI) between 1966 and 1968.2 A joint working party of the Royal College of Physicians and British Cardiac Society dismissed the results of this study because of design defects.3,4 Kalra et al5 performed a randomised trial with ...

Hugh G Dickson

In reply: Dickson argues for exclusion of randomised controlled trials (RCTs) if treatments have changed, but treatments are constantly changing so, following this rule, meta-analysis would be impossible. Similarly, diagnosis has changed — stroke was a clinical diagnosis, then computed tomography was required, and now magnetic resonance imaging is needed. Equipoise is not a requirement for inclusion in a meta-analysis. Complaints about research being simplistic because ...

Gideon A Caplan

Objectives: To examine the rate of detection of alprazolam among cases of heroin-related death (HRD) in Victoria, including the relationship between alprazolam supply and HRDs.Design and setting: Population-based study of community alprazolam supply in Victoria and HRDs reported to the Victorian coroner from January 1990 to December 2010.Main outcome measures: Number of prescriptions for alprazolam supplied; defined daily dose (DDD) ...

Angela C Rintoul BA, MSocSci · Malcolm D H Dobbin MB BS, PhD, MPH · Suzanne Nielsen BPharm, BPharmSc, PhD · Louisa Degenhardt BA(Hons), MPsychology(Clinical), PhD · Olaf H Drummer PhD(Med), BAppSc(Chem), FRCPA

Why is performance reporting necessary? Is there any evidence of benefit? And how can it help busy doctors, nurses and allied health clinicians?

Diane Watson PhD

Clinical registries are at a crossroads. Will we continue the current patchwork approach or will we make the changes that are needed to improve the efficiency and effectiveness of data collection and drive the quality of care?

Sue M Evans MClinEpi, PhD · Bebe Loff BA LLB, MA(MedLaw · Peter A Cameron MB BS, MD

To the Editor: The impact of population ageing on health care expenditure was a hot topic in the late 1990s in Australia.1 Previous studies have adopted various modelling approaches to estimate age- and sex-specific health care costs to inform population health care expenditure projections.2-4 Medicare funds about 3800 medical services, including consultations provided by general practitioners and specialists, medical diagnostic services (such as medical imaging and ...

Catherine L Keating

A qualitative study explores the experiences of patients treated for trauma in Victoria, revealing gaps in communication, information provision and post-discharge care.

Belinda J Gabbe MAppSc, MBiostat, PhD · Jude S Sleney BSc(Hons), MSc · Cameron M Gosling BAppSc(HM), GradDip(ExRehab), MAppSc · Krystle Wilson BN(Hons) · Melissa J Hart RN, Orth Cert, BEd, · Ann M Sutherland RN, AdvCertM’ment, GradDipOHE · Nicola Christie BA, PhD

CorrectionAuthorship statement omitted: In “Secondary prevention of coronary heart disease in Australia: a blueprint for reform” in the 4 February 2013 issue of the Journal (Med J Aust 2013; 198: 70-71), a full statement of authorship was omitted. Julie Redfern and Clara Chow coauthored the editorial on behalf of the Executive Committee and all participants in the National Secondary Prevention of Coronary Disease Summit held in December ...

Julie Redfern* BSc, BAppSc(Physio), PhD · Clara K Chow* MB BS, PhD, FRACP

Whether it’s trialling new methods of service delivery or critically evaluating established practice, true innovation involves renewing, changing or creating more effective ways of doing things.

Ann Gregory · Ruth Armstrong

To the Editor: The recent article by Elshaug and colleagues identifying potentially low-value health care practices1 does not distinguish between surgery for obstructive sleep apnoea (OSA) in adults (which is largely used as an adjunctive or salvage intervention in Australia) and children (which is primarily a first-line intervention). Their article excludes high-level clinical trials in OSA surgery in adults that reflect closely protocols used in a ...

Stuart G MacKay

To the Editor: Elshaug and colleagues identified chlamydia screening of under-25-year-olds in the general population as a potentially low-value health care practice.1 They cite a systematic review that found that evidence from randomised controlled trials (RCTs) on the impact of chlamydia screening on reducing pelvic inflammatory disease (PID) was limited to high-risk populations, had methodological limitations and had never involved repeated rounds of screening. However, ...

Jane S Hocking · Basil Donovan · Rebecca Guy

To the Editor: The article by Elshaug and colleagues on potentially low-value health care services raises an important issue, given spiralling health care costs and limited resources. However, we are concerned by the authors’ claim that use of prophylactic implantable cardioverter defibrillators (ICDs) “did not reduce the risk of death, was more expensive and less effective than control therapy”. Elshaug and colleagues did not consider ...

Kim H Chan · Justin Ghosh · Mark A McGuire

To the Editor: The Medical Journal of Australia’s recent focus on making the best use of finite health resources is an essential discussion if Australia is going to continue to enjoy a high-quality and affordable health care system. One study identified large-scale use of resources on health care practices with no proven benefit. In my area of oncology, these included the overdiagnosis and overtreatment of many ...

Ian E Haines

In reply: In this issue of the Journal, several correspondents weigh in on our recent article in which we flagged services of potentially low value within Australia’s Medicare Benefits Schedule (MBS).1 Their letters highlight informative and unique reactions to such work. I would like to begin by clarifying that we are not the party suggesting items are of low value. Rather, we have flagged items that ...

Adam G Elshaug

Is activity-based funding stifling the use of new technologies in the public sector?

Michael D Coory · Bridie S Thompson · Susan J Jordan

The authors explore the reasons for barriers to discharge from inpatient rehabilitation and whether these can be predicted by demographic or clinical variables.

Peter W New MB BS, MClinEpi, FAFRM(RACP) · Damien J Jolley MSc(Epidemiol), MSc, A Stat · Peter A Cameron MB BS, MD, FACEM · John H Olver MB BS, MD, FAFRM(RACP) · Johannes U Stoelwinder MB BS, MD, FRACMA