Health services administration

Clinical practice guidelines are useful, but there is much more to delivering optimal care in the primary care settingThe CareTrack study reported by Runciman and colleagues in this issue of the Journal raises serious concerns about the delivery of appropriate health care in Australia.1 Yet we have some of the strongest benchmarks internationally,2 and Australia is one of the world’s healthiest countries.3 How can this ...

Evan Ackermann MB BS, FRACGP

How appropriate is the health care delivered to Australians? A seminal study in the United States showed that American adults received “recommended care” only 55% of the time in the years 1999–2000. Estimates of “appropriate care” — defined here as care in line with evidence-based or consensus-based guidelines — are limited in most countries, including Australia, to small groups of conditions ...

William B Runciman MB BCh, FANZCA, PhD · Tamara D Hunt BAppSc(Nursing), CritCareCert · Natalie A Hannaford DipAppSc(Nursing), MPH · Peter D Hibbert BAppSc(Physio), GradDipComp, GradDipEcon · Johanna I Westbrook PhD, GradDipAppEpid, MHA · Enrico W Coiera MB BS, PhD, FACMI · Richard O Day MD, FRACP, MB BS · Diane M Hindmarsh MScAgr, MBiostats · Elizabeth A McGlynn PhD · Jeffrey Braithwaite PhD, MBA, FCHSM

To the Editor: It has been estimated that “levelling the playing field” in terms of cardiovascular health alone could narrow the life-expectancy gap between Indigenous and non-Indigenous Australians by 6.5 years.1 While there has been a particular (and important) focus on risk factor modification, and prevention and management of chronic disease, it is worth noting that, compared with other Australians, Aboriginal and Torres Strait Islander people have: three ...

Robert D Grenfell · Vicki Wade · Eleanor Clune · Kelley O’Donohue · Prue Power

To the Editor: Rates of health care-associated Staphylococcus aureus bacteraemia (HCA-SAB) and hand hygiene (HH) compliance are now subject to public disclosure on the MyHospitals website (http://www.myhospitals.gov.au). HH compliance and HH alcohol hand rub and liquid soap procurement have been associated with reduced methicillin-resistant (but not methicillin-sensitive) S. aureus bacteraemias, generally in the presence of other co-interventions.1,2 However, the National Hand Hygiene Initiative advocates that ...

E Geoffrey Playford · David McDougall · Mary-Louise McLaws

PROPOSALS FOR CHANGE, states Machiavelli, with whom the book opens, are met with retaliation from those “who do well out of the old order”. Jorm’s book regards “the old order” as “senior consultants doing it this way for twenty or thirty or forty years”. But another, more recent, order is also under fire: the increasing bureaucratic regulation of medical practice enacted by “primitive and poorly ...

Rick A M Iedema

Is now the time to send a signal that poor-quality care should not be rewarded in activity-based funding?Public hospitals in Australia are in for a shake-up over the next few years, with boards being reintroduced in many states and activity-based funding (ABF) being rolled out nationally.1 ABF will replace global or historic budgets for hospitals in most states. National casemix classifications will be agreed, and ...

Stephen J Duckett PhD, DSc, FASSA

To the Editor: Complementary medicines may lack evidence of safety and efficacy, but conventional medicine lacks evidence of efficacy in 30%–40% of cases,1 and the breast implant and hip replacement debates demonstrate safety concerns. The debates about conventional versus complementary medicine expose how out of touch the medical profession is with the views of government and the people about complementary medicine. The medical profession was ...

Simon J Spedding

Clear guidance is needed on what information should be publicly available, and for how long. One of the fundamental realignments that has occurred to the doctor–patient relationship is the capacity of patients to acquire information from the internet and, on the basis of it, interact with their practitioners in new and different ways. Some of the ...

Ian R Freckelton BA(Hons), LLB, PhD

Ray Moynihan hears a new professional–consumer alliance ringing the alarm on overused interventionsSometimes truth is stranger than fiction. In the United States a few weeks ago, nine leading doctors’ groups published lists of the top five overused tests and treatments within their specialty areas.1 What’s more, they did it with enormous fanfare and in partnership ...

Ray N Moynihan BA

To the Editor: We read Scott and Harris’s1 article with great interest and agree that new funding models for diabetes care must be carefully designed to ensure that interventions are effective. For this reason, the Diabetes Care Project2 (formerly the Coordinated Care for Diabetes Pilot) developed pilot interventions following reviews of international trials and extensive ...

Tim Fountaine · Jonathan E Shaw · Paul Z Zimmet

Most specialised mental health services in Australia are delivered in community settings and one in six services comprise involuntary treatment. Despite a growing demand for community treatment orders (CTOs) worldwide — and comparatively high rates of use in Australia — the clinical, legal and ethical aspects of CTOs remain contentious. This article examines ...

Edwina M Light BA(Comms), GradCertJournalism, GradCertBioethics · Ian H Kerridge MPhil, FRACP, FRCPA · Christopher J Ryan MB BS(Hons), MHL, FRANZCP · Michael D Robertson MB BS(Hons), FRANZCP, PhD

To the Editor: We read with interest the article by Geelhoed and de Klerk1 regarding the mortality benefits of a policy that ensures high numbers of patients are admitted to hospital within 4 hours of arrival at an emergency department (ED). The proof of improved performance following service intervention within a complex institution requires careful consideration. ...

Dylan J Toh · Campbell H Thompson · Josephine S Thomas · Jeffrey Faunt

In reply: We thank Mitra and Cameron, and Toh and colleagues for their remarks. Comments from some physicians that the 4-hour rule might increase mortality provided the initial stimulus for us to look at data related to its introduction in Western Australia. Given our results, their hypothesis seems unlikely to be true. Mitra and Cameron point ...

Gary C Geelhoed · Nicholas H de Klerk

To the Editor: The HIV epidemic in Australia is changing. The number of new infections attributed to heterosexual contact has increased, and people from culturally and linguistically diverse (CALD) backgrounds account for a significant proportion of these diagnoses. In the period 2005–2009, 41% of new HIV diagnoses linked to heterosexual transmission were in people from ...

Augustine D Asante · Henrike Körner

The medical profession is ageing in parallel with the wider community, with more Australian doctors working into their 70s. This has implications for workforce planning and raises questions about competence. However, no Australian specialist college has policies relating to the special circumstances of ageing practitioners. Ageing practitioners are affected by a number of age-related ...

George A Skowronski FRCP, FRACP, FCICM · Carmelle Peisah MB BS(Hons), MD, FRANZCP

Data sharing would speed progress in improving the Australian health systemThe benefits of data sharing have been demonstrated in genomics, where it has accelerated progress and provided an understanding of complex issues sooner.1 Hoping to ...

Michael D Coory MB BS, FAFPHM, PhD · Craig L Fry BSc(Hons), DrPH

To the Editor: Clinical training opportunities are a vital component of medical student education.1 The yearly intake of medical students into Australian universities has more than doubled since 2000.2 There is a need for increased ...

Mark K D Tiong · Michele R Levinson · John C Oldroyd

To the Editor: The editorial by Seibel1 was timely, given the promotion in February last year by the New South Wales Agency for Clinical Innovation of an osteoporotic refracture prevention model of care. The evidence presented by Seibel is compelling — osteoporosis is a serious, undermanaged and preventable problem, and there are no more excuses for not instituting refracture prevention protocols in major teaching hospitals. Not only do these programs work to prevent further patient morbidity and mortality, but they are cost-effective in reducing the burgeoning public hospital costs associated with recurrent fractures and hospital admissions. We question the delay in implementing such programs. One cost analysis showed that treating 214 patients saved $156 713 and reduced hospital stays by 270 bed-days over a 2-year period (John Van der Kallen, Rheumatologist, Hunter New England Local Health District, personal communication). More than 10 years ago, we demonstrated that minimal trauma fractures were inadequately managed and preventable, and outlined a cost-effective clinical pathway for monitoring and treating these patients when they presented through the emergency department.2-5 Had this program been instituted by the medical administration at that time, there would have been a saving over a 10-year period of more than $2 million by one major Sydney teaching hospital alone. Despite much talk and “hype” on the part of medical and allied health professionals, medical administrators and government agencies, nothing has eventuated. Unless there is an injection of funds from health departments and a willingness from hospital administrators to implement such programs, we believe that “nothing” will be what continues to happen.

David Spencer · Graydon Howe · Nicholas Manolios

To the Editor: The recent article by New and colleagues1 is an important piece in the “bed-block” picture, providing insight into perceived difficulties for patients on discharge, as a result of insufficient appropriate facilities. The authors suggested that “Redistributing proposed funding for inpatient subacute beds to measures for overcoming these barriers” may improve patient flow through the whole hospital system. This idea fits well with current federal health policy that “bed equivalents” are an important aspect of innovative and flexible models of care for rehabilitation services in Australia.2 Most states are reviewing how rehabilitation services are best designed to ensure the most effective use of limited resources, both in terms of programs and workforce. Improving the coordination of programs managed by the various levels of government, across health, disability and the aged care sectors, will help overcome the barriers identified in this study. The Australasian Faculty of Rehabilitation Medicine applauds efforts to increase research on rehabilitation and patient care, and supports federal and state initiatives providing increased resources for subacute care, both within hospitals and in the community. Investment in rehabilitation services at the community level is one of the most viable solutions and will meet the needs of an ageing population. Effective community care and the proposed National Disability Insurance Scheme (http://www.ndis.gov.au), if well executed, will reduce the burden on other parts of the health and aged care sectors and help ease the burden on hospitals.

Kathleen McCarthy

Objective: To estimate the number of cancers to be diagnosed in 2025 that could be prevented solely due to changes in diet and physical activity.Design and setting: We used an Australian population-based cancer database to estimate the total number of cancers to be diagnosed in 2025, by applying published age- and sex-specific population projections to current cancer incidence rates, and multiplying the projected numbers of cancers by estimates of population-attributable fractions.Main outcome measures: Projected number of preventable cancers that would be diagnosed in 2025.Results: Our projections suggest that there will be about 170 000 Australians diagnosed with cancer in 2025. This represents an increase of about 60% on the 2007 incidence. Almost 43 000 of these cancers (low estimate, 42 295; middle, 42 657; high, 43 990) could be prevented through improvements to diet and physical activity levels, including through their impact on obesity. It is likely that this is an underestimate of the true figure. The most preventable cancer types in 2025 were estimated to be bowel cancer and female breast cancer (10 049 and 7273 preventable cases, respectively).Conclusions: About 25% of cancers, or about 43 000 cancers in 2025, can potentially be prevented through improvements in diet and physical activity. It is imperative that governments, clinicians and researchers act now if we are to reduce the significant future human and financial burden of cancer.

Peter D Baade PhD · Xingqiong Meng PhD, MD · Craig Sinclair MPPM, BEd · Philippa Youl MPH