Health services administration

Significant problems in health care, such as access block and long waiting lists for elective surgery, have led to calls for keeping hospital occupancy at no more than 85%. It is elementary queueing theory that a finite-capacity system with variable demand cannot sustain both full utilisation and full availability. However, the statement that there is a single level of ideal or safe occupancy suitable for all situations is a simplistic interpretation and application of the underlying science. We argue that specific study and action are necessary to understand and deal with the problems of long waiting lists and access block in any given health care facility.

Christopher A Bain MB BS, MInfoTech, MACS · Peter G Taylor BSc, PhD · Geoff McDonnell FRACP, MEngSci, MIEEE · Andrew Georgiou PhD, FACHI

To the Editor: On behalf of the Australian Medical Council (AMC), I would like to comment on a recent article1 and two letters2,3 in the Journal about the content of the AMC’s Good medical practice: a code of conduct for doctors in Australia (“the Code”)4 and the consultation process used to support its development. The AMC developed the Code on behalf of state and territory medical boards. It was endorsed by the AMC directors and will be recommended to the new Medical Board of Australia, due to be established later this year. The Code was strengthened by a robust consultation process (supported financially by the Australian Government Department of Health and Ageing) and has been supported by members of the medical profession and the community.5,6 Myers2 seems unaware of the make-up of the AMC, which includes nominees of its many stakeholders (including medical boards). He also seems to be unaware that medical boards in Australia (including the Medical Practitioners Board of Victoria) have already issued codes of professional conduct and that the new national Code brings together and builds on the key elements of these existing codes. The core roles of the AMC are the assessment of international medical graduates on behalf of state and territory medical boards and the accreditation of Australian medical schools and medical colleges. It is not the role of the AMC to “evaluate . . . laws and regulations” or to “address the issue of the accountability of regulatory bodies”, as suggested by Myers. Komesaroff and Kerridge1 and Myers2 appear to believe that a code of professional conduct can be legally binding. Although disciplinary tribunals may use the Code as a guide in their task of assessing allegations of unprofessional conduct, the most important role of the Code is to guide doctors about professionally acceptable conduct. Such conduct is based on many elements, but must especially encompass conduct that is consistent with both professional and legal standards developed by the profession and by parliaments, respectively. It would be neither feasible nor useful to develop a code to guide doctors in meeting those standards in their daily work, without reference to the law and to ethical and professional standards. The Code is not designed to enforce particular kinds of outcomes, but does have an educational focus, and we believe it will contribute to informing and enriching practice. Perhaps Komesaroff, Kerridge and Myers would do well to familiarise themselves with the codes of conduct already in place around Australia and to recognise that they have been used for many years by medical boards to assess complaints about doctors’ conduct. The final code is available online.4 It will be interesting to observe how it is used in the years ahead.

Richard A Smallwood

To the Editor: Robertson and Kerridge1 criticised our article “Patient privacy versus protecting the patient and the health system from harm”2 based on an interpretation that we were advocating notification for all patients with somatisation disorders, but our recommendation for a confidential notification system pertained specifically to factitious disorder. We agree that “ignoring or failing to integrate mental health care in future health planning is to invite a higher burden of morbidity, mortality and cost”.1 Indeed, we do not wish to “[constrain] the patient’s interaction with the health system”, but rather believe that a more complete, accurate and easily available patient history would allow doctors to optimise such patients’ care within the system. Clinically appropriate resource allocation would substitute appropriate psychiatric/psychological and primary care for more costly and inappropriate (potentially harmful) emergency and procedural care, such as numerous cardiac catheterisations. The case described in our article illustrates well the higher burden of morbidity and cost that the patient, and the system, had to endure because of the failure of multiple health providers across a range of acute settings to diagnose and treat the patient’s primary illness.2 Avoidance of truthful disclosure on the part of the patient contributes to this diagnostic failure. An electronic medical record (EMR) notification in this kind of case would allow any given doctor to overcome the otherwise almost insurmountable barriers to collating such a patient’s history, and thus to be aware of, to balance and to manage the factitious disorder diagnosis — a notoriously difficult task.3 Robertson and Kerridge argue there is a lack of evidence for “costly” EMR systems. However, it has been found that “Hospitals with automated notes and records [have] fewer complications, lower mortality rates, and lower costs”.4 A truly private portable EMR should help all patients obtain more appropriate and cost-effective care, by reducing duplication of costly investigations and doctors’ time spent chasing records. Conversely, patients might reasonably abhor a privacy system that inadvertently results in duplicate computed tomography scans — the prior records being “private” and unavailable — when radiation exposure increases the risk of cancer.5 We would be the first to acknowledge the risk of “stigmatisation” and agree with safeguards to mitigate potential consequences, as mentioned in our article.2 However, in the case of this patient and others in a similar situation, we still believe that he, the doctors struggling to provide appropriate care, and the system deserve better, which certainly won’t happen with the status quo.

Dawn E DeWitt · Ravi Bhat · Stephanie Ward

To the Editor: My compliments on the issue of the Journal on the survival of general practice (20 July 2009). But something was missing — a patient’s perspective. I hear from fellow Sydneysiders that they cannot find a general practitioner offering continuity of care. They tell me that: All recommended GPs have “closed books”. They can’t get an appointment on the day and have to wait until a few days later, unless it’s a “real emergency”. At big, “commercial” practices, they seldom see the same GP again — and must tell their story each time. Their GP (preferably female) is there some weekdays only. They can’t find a GP who does home visits. Neither “their” GP, nor any of the others in the practice, is available after hours — they must ring an emergency doctor with no access to their records. GPs want them out quickly with a prescription or referral. GPs say that, although it’s a simple procedure, it’s better done by a specialist. GPs want to start a “care plan”, even if there’s nothing much wrong. They’re not happy with attention from the nurse — they want to see the doctor. And so it goes. Back in 2006, the Australian Consumers Association, together with advice on choosing a GP, commented: The relationship you have with your doctor can be one of the most crucial in your life ... A positive ongoing relationship with your GP is extremely valuable, making it all the more important to choose the right one.1 Shouldn’t the MJA open its pages — on an issue which matters so much to them — to patients, to air their concerns? As it would be anecdotal, we would need evidence. A recent article in the BMJ surveyed British attempts at harnessing the views of patients.2 The authors’ opening comments were: “There is now a widespread realisation that patients’ views are not optional but essential to achieving high quality care.” Similarly, Australian patients’ expectations about weight management in general practice were discussed in the Journal in 2006.3 Is general practice’s survival not about adapting to meet patients’ requirements for high quality of service? In special issues devoted to the adaptation of general practice to future change, should not bodies like the Australian Consumers Association and some of the patient support groups, such as Arthritis Australia, be asked to contribute? Perhaps the MJA’s discussion is missing the wood for the trees?

Peter C Arnold

This year witnessed the roll-out of a suite of reports on the delivery of health care in Australia, ranging from the role of preventive health,1 to the potential directions of primary care,2 the state of Australia’s public hospital system3 and our health care system in general.4 Specific protocols were presumably followed in assembling these reports, employing a convention familiar to doctors: evaluation of systemic symptoms and signs, formulation of diagnoses, and recommendations for appropriate action. However, with the occasional exception,3,5 this cavalcade of reports — despite their long lists of recommendations — failed to provide any substantial blueprints for reform. Absent were any comprehensive and detailed plans outlining remedial action, necessary time frames and attendant costs. It is vital that such essential details be specified in any future reports recommending health care reform. The reasons why we have been inundated by inquiries and reports since the election of the Rudd Labor Government remain obscure, known only to those with access to privileged Cabinet documentation. But in the absence of a comprehensive pre-election health care policy, we may well speculate that this blitzkrieg of inquiries was a means to fill Labor’s bare policy cupboard. Whatever the reasons, it could be stated that there remains an elephant in the room of health care reform: the inexorable and apparently uncontrollable upward trend of the cost of Australian health care. Australians consume about $100 billion of health services each year, amounting to about 9% of gross domestic product.6 Fifty years ago, we only spent about a third of this amount on health care. Moreover, it is projected that in the next 25 years, health and aged care spending will increase to almost $250 billion per year.6 Commenting on this phenomenon, Tom Dusevic, national affairs correspondent for the Australian Financial Review, claimed: Left unchecked, health spending could eat up the entire budget of the states within a generation — leaving nothing for schools, roads, police and other essential services.6 In Australia, we have never had a serious community debate about how much we may actually wish to spend on health care. Nor have we dared to address the even more thorny issue of where our health care dollars should be allocated. Instead we resort to covert rationing, such as blow-outs of elective surgery waiting times and other forms of access rationing. Perhaps the time has come for yet another, even more important, inquiry to openly examine resource allocation in health care — an inquiry that looks at all the multipliers embedded in such a complex and layered system, such as the burgeoning and bloated bureaucracies or our ageing population making decisions of increasing urgency as to how they will spend their last years. It should also advance the means to continuously cost health interventions and tailor these to individual episodes of care and institutions. Without this kind of continuous and current fiscal data, the impact of reform on health care costs will be no more than guesswork. One can only hope that a holistic and all-embracing inquiry will offset the federal Health Minister’s current monstering of the Australian medical profession vis-a-vis Medicare rebates.7-9 Scapegoating, especially in the absence of hard data, is the refuge of those who wish to oversimplify the debate and divert attention from questionable decisions about the allocation of resources. The recent stoush with Australian ophthalmologists over the Medicare rebate for cataract surgery8 is one such altercation, which presumably has its rationale in the desire to contain health costs. However, its barely concealed stridency has become increasingly tainted by ideology and the politics of envy. The same factors are presumably driving Labor’s doctor displacement agenda.10 If we are to pursue reform, the elephant in the room — namely, the inherent multiplier effects of these reforms on the cost of health — should be transparent and debated with all stakeholders.

Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To examine activity patterns of the Royal Flying Doctor Service of Australia (RFDS) in far western New South Wales and to determine whether frequent use of RFDS services, particularly emergency evacuations, is a useful indicator of patients who may benefit from care planning and review.Design, setting and participants: We conducted a retrospective audit of the RFDS South Eastern Section’s Broken Hill patient database. Patients with a residential address in the study area who had accessed at least one RFDS medical service between 1 July 2000 and 30 June 2005 were included in the study.Main outcome measures: Number of evacuations, clinic consultations and remote consultations; clinic usage by frequent evacuees; number of primary diagnoses recorded for frequent evacuees; number of frequent users who might benefit from multidisciplinary care or specialist shared care.Results: Between July 2000 and June 2005, the number of residents requiring evacuation or remote consultations declined by 26% and 19%, respectively, and the number of residents accessing clinics declined by 6%. (Over the same period, the population of the study area fell by about 24%.) Of the 78 patients who were identified as frequent users of the evacuation service (≥ 3 evacuations/year), 34 had three or more primary diagnoses recorded; 15 were infrequent or non-users of the clinics (≤ 3 attendances/year); 53 may have benefited from multidisciplinary care, and 41 from specialist shared care.Conclusions: Simple, practical clinical review systems can help health care organisations in rural and remote communities to achieve better outcomes by identifying patients who may benefit from planned care.

David L Garne MB ChB, DCH, MIPH(Hons) · David A Perkins BA(Hons), PhD · Frances T Boreland BA(Biol)(Hons), MPH(Hons) · David M Lyle MB BS, PhD, FAFPHM

Objective: To evaluate the acceptance and cost of a ward-based geriatric consultation service delivered via a mobile videoconferencing system.Design and setting: Prospective observational study conducted in the geriatric unit of Toowoomba Base Hospital, Queensland, comparing a specialist consultation service delivered by videoconference (VC) with a “traditional” in-person service. The VC system was established in January 2007 and evaluated over an 18-month period. Patient satisfaction with the service was assessed by questionnaire during a 1-week period in September 2008.Main outcome measures: Hospital acceptance of the service; patient satisfaction with the service; comparative cost of providing in-person and VC-mediated consultations.Results: Uptake of the service increased progressively throughout the study period. Patient acceptance levels were high. The cost of video consultations for a 12-patient ward round and case conference was less than the cost of in-person consultations if the total road distance travelled by the specialist (Brisbane to Toowoomba and back) was 125 km or longer.Conclusion: Consultations via VC are an acceptable alternative to in-person consultations, and are less expensive than in-person consultations for even modest distances travelled by the clinician.

Leonard C Gray MB BS, PhD, FRACP · Olivia R Wright PhD · Alison J Cutler MB BS, FRACP · Paul A Scuffham BA, PhD · Richard Wootton DSc, PhD

Health services research is now a top priority for the National Health and Medical Research Council Health research has many objectives. It can develop fundamental knowledge about human health and what causes ill health, improve means of diagnosing diseases and treating patients, provide evidence for preventive health strategies and interventions, invent new devices and agents to treat and cure disease, and provide the community with better knowledge on how to safeguard their health and wellbeing. It is therefore surprising that the health system has historically been the focus of much less research than has been concentrated on the health of individuals. During the past decade, Australia has increased its research effort into public health and preventive health through National Health and Medical Research Council (NHMRC) funding, from a budget of $10.6 million in 1997 — the last year of the Public Health Research and Development Committee (PHRDC) — to $91.5 million in 2009. (The PHRDC was established by the NHMRC in 1987 in response to the Kerr White Report,1 published in the mid 1980s; in 1997, its role was absorbed, along with that of the then Medical Research Committee, into the newly created NHMRC Research Committee.) But health services research has lagged and in 2009 attracted only $32.4 million (out of a total NHMRC research budget of $706.9 million). Of 3111 applications received by the NHMRC for project grants in 2009, only 134 (0.4%) were categorised by applicants as being for health services research. There is further support for health services and systems research from the health system itself, but little by way of a coordinated approach that recruits the most able researchers. In 2006, the NHMRC made a commitment to increase its support of health services research — in line with the recommendations of the Investment Review of Health and Medical Research review committee chaired by John Grant, which reported in 2004 to the then Minister for Health and Ageing.2 A special advisory group was established by the NHMRC, chaired by Professor Sally Redman of the Sax Institute and the University of Sydney, to set up a framework to influence and support the infusion of evidence from research into improving the health care system and the actions of health professionals, and into public health policy. This committee completed its work in early 2007, and its report was considered by the NHMRC’s Research Committee and Council.3 Both agreed that the NHMRC Partnerships for Better Health initiative be established. In 2008, the NHMRC committed $250 million over 5 years — commencing in 2009 — to support the Partnerships for Better Health initiative, which comprises two key initiatives. The first key initiative is the Partnership Projects scheme, which aims to: provide support for research that addresses the delivery, organisation and funding of programs and services that affect health; and encourage researchers and partner organisations to form alliances to identify research projects, conduct research, interpret their findings, and promote the use of their findings to influence design and evaluation of health and health care policy and practice. As with all NHMRC funding schemes, a rigorous peer-review process was established for this scheme to ensure that only the best research and researchers would be funded. Applications for Partnership Projects were called for on 25 July 2008 and closed on 19 December 2008. This longer than normal application period was considered essential, given that a requirement of applications was that a partnership be established between applicants and organisations involved in health care. One hundred and thirteen applications were received, with a wide range of health bodies partnering health researchers. The applications were reviewed by a panel that consisted of experienced health services researchers (including two from New Zealand), as well as experienced, research-trained state and federal health officers. The 27 successful applications, valued at a total of $21 million, were announced by the Prime Minister on 16 October 2009. They cover a wide range of health services research, including: improving services for people with dual sensory impairment (vision and hearing); improving maternity care services; studies in general practice (including guideline implementation for chronic disease, Indigenous primary care services and diabetic retinopathy monitoring); acute stroke care; sports safety; hepatitis C assessment and treatment in drug users; allied health services in rehabilitation; childhood mental health; system design for the care of pregnant women with diabetes; public health interventions to reduce metabolic syndrome; patient-centred chronic care in Indigenous communities; rural cancer care; and improving hand hygiene in health care settings. A full list of these grants is available at http://www.nhmrc.gov.au/grants/partnerships.htm. The partner organisations, which have committed to work with the researchers with a view to improving health policy and practice, include state health authorities and non-government organisations, as well as community groups, Indigenous community groups and commercial associations. Other partner organisations include: Australian Commission on Safety and Quality in Health Care Sydney South West Area Health Service Australian Football League Hepatitis C Council of NSW Cancer Council Australia Water Quality Research Australia Australian Food and Grocery Council Diabetes Australia Australian Red Cross Blood Service Epilepsy Australia National Stroke Foundation. The second key initiative in the Partnerships for Better Health initiative will be the Partnership Centres for Research Excellence program. This will promote collaboration between researchers and those working in health and the health care system, and will be announced in 2010. A discussion document developed by an international team — Jonathan Lomas (former Director, Canadian Health Services Research Foundation), Sally Davies (Director General, Research and Development, Department of Health, United Kingdom) and Chris Baggoley (Chief Executive Officer, Australian Commission on Safety and Quality in Health Care) — was released for discussion as part of a final consultation process in July 2009.4 The NHMRC Research Committee will consider this feedback in late 2009. To further promote health services research, the NHMRC introduced the Capacity Building Grants in Population Health and Health Services Research program in 2008, which in 2009 was transformed into the Centres of Research Excellence Scheme. This scheme does not require contributions from partner organisations, and aims to support teams of researchers to pursue collaborative research and develop research capacity in health services. The cost to Australia of its health system is more than 9% of its gross domestic product, and exceeded $100 billion per year for the first time last year.5 Although many health professionals do not like to regard health care as an industry, it is the second largest employer of Australians and most of us use its services each year. High-quality research and development is therefore essential for developing a health system that operates on the basis of evidence and ensuring that the health system can be, in the words of the National Health and Hospitals Reform Commission, an “agile, self-improving” system into the future.6

Warwick P Anderson BSc(Hons), PhD · Elim M Papadakis BA(Hons), PhD

Objectives: To explore National Health and Medical Research Council (NHMRC) funding for each National Health Priority Area (NHPA) over time and by grant type, and to quantify the relationship between grants awarded and a range of measures of societal burden of disease (BoD).Design and setting: We conducted a retrospective analysis of NHMRC funding for each NHPA from 2000 to 2008 to assess the strength of correlation between level of NHMRC funding and contribution of each health condition to BoD. Information on mortality, incidence, prevalence, “healthy” years of life lost due to disability (YLD), years of life lost due to premature mortality (YLL) and disability-adjusted life-years (DALYs) was obtained from the 2003 Australian BoD study. Information on health system expenditure for each NHPA was obtained from an Australian Institute of Health and Welfare report.Main outcome measures: Observed versus expected number of grants; amount of funding allocated to each NHPA; relative contribution of each NHPA health condition to BoD.Results: 6099 new and continuing NHMRC grants were linked to NHPAs. Total NHMRC funding by NHPA was strongly correlated with YLL and DALYs, but there was no clear association between the amount of funding per NHPA and YLD or health system expenditure. Based on the proportional contribution of each NHPA health condition to total NHPA-related DALYs, a higher than expected number of grants was allocated to diabetes and cancer research, and a lower than expected number to injury and mental health research.Conclusions: Some of Australia’s NHPAs are better funded than others. The NHMRC could begin to redress this imbalance by allocating research and workforce development funding to less well developed research areas to ensure appropriate resourcing that is commensurate with their contribution to BoD.

Rebecca J Mitchell MA(Psych), MOHS, PhD · Rod J McClure PhD, FAFPHM · Jake Olivier PhD · Wendy L Watson BSc(Hons), MA, PhD

Surgeons v physicians: when push comes to shove, there’s “us” and there’s “them” Physicians and surgeons are natural enemies. It is nothing personal: just as the lion circling for the kill affords its wildebeest prey no malice, the mutual antagonism between surgeon and physician is simply a law of the medical jungle. The antipathy that each group holds for the other is submerged in the shallow waters of professional courtesy, but when, on occasion, the true feelings of either tribe breaches the surface, the medical student initiate may be in for quite a shock. On the outside, relations might appear quite amicable — matey even — but try this experiment: ask your student whose next rotation is with a surgeon to casually drop the term “evidence-based medicine” into the conversation in the operating theatre. Look, I’ll admit this up front — some of my best friends are surgeons. I have shared their table, been on holiday with them, coveted their new convertibles and drunk too much of their 18-year-old single malt whisky. But the fact remains that when diagnostic push comes to therapeutic shove, I am one of “us” and they are one of “them”. In the second year after entering the workforce, young medical graduates are faced with a crucial decision: will they become surgeons or physicians? In theory, there are dozens of other vocational choices (general practice, psychiatry, pathology, radiology and emergency medicine, to name a few), but for the surgeon and physician, these other paths are hardly worth considering — the “real” doctors, they believe, have only a dichotomous choice. Sometimes, the novices are unable to make up their minds and are submitted to a number of vocational aptitude tests, including being asked to comment on the following scenario: A surgeon, a physician and a pathologist go away for a weekend of duck shooting. They row their punt to the middle of a lake and decide to take turns to shoot. First-up is the physician. Suddenly, a flock of ducks flies overhead. The physician takes aim, tracks the path of the ducks with his gun but doesn’t fire. “Why didn’t you shoot, you idiot?” shouts the surgeon. “Well, I was just about to when I glimpsed out of the corner of my eye a tail feather on one of the birds that made me doubt whether these were really ducks at all. I felt that the likelihood of these actually being Anserini geese was high enough for me to hold fire and do a little more research on the local migratory patterns of the two species.” It is the surgeon’s turn next. The sky fills with birds and, without a moment’s hesitation, he lets off 12 rounds from his pump-action shotgun. Birds, feathers and entrails fall into the lake around them. When the air clears, the surgeon pushes the pathologist overboard and says, “See if they’re ducks, will you old chap?” It is, of course, a trick test. If the students haven’t made up their minds before they take the test, then they’re not meant to be surgeons. If they laugh, they can’t become pathologists. If they look up the meaning of “Anserini” then their die is cast as physicians. Do you become a physician because you can’t make quick decisions, or do you choose surgery because, when young, you liked working with the family’s sewing machine and power tools? Was Ben Casey your role model or that lovely Dr Welby? Do you pine for McDreamy or fantasise over Greg House? In other words, are surgeons and physicians made or are they born? Let’s examine this question. It would be reasonable to believe that surgeons require a degree of manual dexterity, yet some are among the clumsiest people I have ever met. One surgeon I knew often arrived at work on Monday with his hands bandaged, having injured himself with his woodworking tools. Another was notorious for losing things — keys, phones, computers, medical documents, two wives and, on one famous occasion, his children. In fact, I have never detected a strong association between talent in the theatre and hand–eye coordination out of it. Most skills of surgery are specific to the operating theatre, and a clumsy-ish person can probably make a decent surgeon. Having said that, I have no doubt that the “gun” surgeons, the ones who other surgeons would allow to operate on them, do have special physical abilities. And there are some subspecialties for which fine motor coordination is a prerequisite. The neurosurgeon and the plastic surgeon must bring a naturally steady hand to the operating theatre; a fine tremor is manageable in the abdominal cavity, but will not do in the unforgiving space of the brain. There’s no prescribed height or weight for surgeons. They come in all shapes and sizes, with one exception — the orthopaedic surgeon. Here is an example of genetic inevitability: what’s bred in the bone really does come out in the medical flesh. The orthopod is an archetype best summed up in the song by the legendary Captain Matchbox Whoopee Band, surely familiar to the discerning reader of a certain age — “Six foot six, broad shoulders, what a whacker!” Outliers in this specialty exist only to prove the rule. If physicians are the thinkers of the profession, then it follows that their ilk should all be gifted scholars. But the young doctors I shepherd through postgraduate training are mainly of solid intellect — more Watson than Holmes. Some are brilliant, but only a very few possess Mensa-level IQs, and this genius often displaces other personality traits such as empathy and humour (the latter being defined as the ability to find my jokes constantly amusing). Physicians pursue a difficult diagnosis by taking a meticulous history and thoroughly examining the patient. They pride themselves on their understanding of pathophysiology and the social determinants of disease. The traditional hallmark of physicians is their ability (and desire) to consider the patient as a whole. These attributes may now be in decline; the interventional specialties, such as cardiology and gastroenterology, have attracted a whole generation of, well, surgeonly physicians who, in some cases, seem more inclined to consider the patient as a hole. Another crucial difference between our two species was summed up by the artist formerly known as Cat Stevens: “The first cut is the deepest”. The surgeon must have the guts to go boldly with a scalpel where no one has (usually) gone before. There is no turning back once you are inside the peritoneal cavity — too late to say, “On second thoughts . . . ” The surgeon must be naturally decisive, prepared to make a call and stick with it. (And here is an important lesson for the young physician dealing with surgeons — remember that your conversation will not work if you try to engage in dialogue. Your physician’s desire for intellectual honesty and explicit depiction of the uncertainty of a course of action will be seen only as weakness.) Surgeons don’t take long histories from their patients or do long ward rounds. In fact, many don’t seem to enjoy consulting much — surgeons like to operate. And if the answer to a problem is not immediately obvious, then it is time to call in the “clever doctors”. This is, of course, an ironic use of the term “clever”, for surgeons don’t really think that physicians possess any more skill or intelligence than they do. In their minds, the only thing that the physician has that the surgeon doesn’t is time. Surgeons are always busy, always somewhere else, or on their way to somewhere else. While the surgeon is doing the doing part, the physician is most likely reading a journal in a library somewhere or talking (yes, talking) to a patient. Physicians usually sleep in their beds at night; surgeons often sleep in their clothes. Although they inhabit the same geographic space, physicians and surgeons live in different worlds. It is not unusual for a physician to pass a week without talking to a surgeon, and vice versa. One thing that can sometimes bring the tribes together is laughter. Walk into any hospital common room and you will find physicians telling jokes about surgeons and, across the corridor, surgeons telling jokes about physicians. And, on the rare occasions that they get together in the same room, surgeons tell the physicians jokes about orthopaedic surgeons. “What is the difference between an orthopaedic surgeon and a carpenter? The carpenter knows the name of more than one antibiotic.” “How do you hide something from an orthopaedic surgeon? Put it in a book.” Or my favourite: “Did you hear that we have employed a holistic orthopaedic surgeon? He cares about the whole bone and not just the fracture.” Physicians, especially those who don’t perform procedures, are ever so slightly jealous of surgeons. They remember the fun they had when they were training, when they could get their hands dirty and do things that had an immediate effect on the wellbeing of their patients: the emergency tracheostomy for the man with an obstructed airway; the immediate relief for the woman following the drainage of her perianal abscess; the appendicectomy for the patient with the, er, normal appendix (OK, forget the last one). They pine for the uninterrupted hours that the surgeon can find in the operating theatre, where the existential thrill of operating insulates them, for a while at least, from the stress of the chaotic and uncontrollable world of the hospital. The physician can be envious of the elegant simplicity of surgery. “You need an operation”, says the surgeon to the patient, “I will do an operation”. The operation is done. “You are better now. Goodbye.” The physician must live with a series of much less conclusive interactions. “You have diabetes”, says the physician, “I will start you on insulin”. The insulin is injected. “You still have diabetes. See you next week (repeat).” Every young person in the course of training to be a doctor dreams, at least for a while, of becoming a surgeon. Hardly any do. Surgeons don’t choose their career, surgery chooses them. Physicians? I’m not sure that the same vocational predetermination applies. Indeed (and it hurts me to say this), happy though your professional life may be, I suspect that sometimes a physician is what you became while you were making other plans . . .

Francis J Bowden FRACP, FAChSHM, MD

We need a national register of home oxygen therapy Oxygen has been used for therapeutic purposes for centuries, but until relatively recently no scientifically rigorous trials had confirmed its true benefits. In the early 1980s, two landmark randomised trials — the Medical Research Council (MRC) trial and the Nocturnal Oxygen Therapy Trial (NOTT) — showed that continuous or semi-continuous oxygen therapy for between 15 and 24 hours a day provided a mortality benefit in patients with chronic obstructive pulmonary disease (COPD) and severe hypoxaemia.1,2 Survival rates for those prescribed “continuous” oxygen (in reality about 19 hours per day) in the NOTT were around 80% at 2 years, compared with around 60% for the “nocturnal” group using oxygen for only 12 hours per day. In the MRC study, in which patients were randomly allocated to receive oxygen for 15 hours per day versus no oxygen, survival rates at 5 years were 67% versus 45%, respectively. This evidence-based treatment is now enshrined in guidelines for managing chronic lung disease locally and worldwide. The Thoracic Society of Australia and New Zealand’s position statement on home oxygen also suggests it may be beneficial for those whose resting daytime oxygen levels are satisfactory, but who experience oxygen desaturation only at night or only during exertion. However, the statement acknowledges the lack of a strong evidence base for use of home oxygen for either of these indications.3 Research to bolster the knowledge base for use of oxygen nocturnally or during exertion, and to examine the effects on mortality of continuous oxygen therapy for patients with COPD and only mild hypoxaemia, was identified as a high priority at a recent workshop on oxygen therapy in COPD initiated by the United States National Heart, Lung, and Blood Institute.4 The MRC trial and the NOTT included only patients with COPD. The patients studied were predominantly men, aged under 70 years, and with few comorbidities. Today, patients commencing long-term oxygen therapy are often older and sicker, they frequently suffer from several other serious illnesses, and more women are affected than previously. Although COPD is still the most common reason for commencing home oxygen therapy, many patients have lung diseases other than COPD. In 2004, the users of home oxygen in South Australia were reported to have a mean life expectancy of 2.9 years; this compared unfavourably with the life expectancy of a demographically similar French population of oxygen users (5.2 years),5 and with the survival data from the original MRC trial and the NOTT. Although ethical issues would preclude conducting further randomised trials to confirm a survival advantage in current oxygen users, we should monitor the use of this intervention to maximise benefits as well as to inform future research. Recent data suggest that nearly one in five Australians over the age of 40 years has COPD6 and, with these numbers expected to rise as our population ages, the number of Australians requiring oxygen therapy will also increase. To maximise the mortality benefit, patients need to use their oxygen as prescribed — for at least 15 hours or more a day. The few studies of adherence to a home oxygen regimen have found adherence rates of only 40%–50%.7 Understanding the difference between the use of oxygen to relieve dyspnoea (which may or may not occur), and its use for prolonged periods of the day to lower mortality by relieving hypoxaemia, requires intensive patient education. Accordingly, the distribution of oxygen should not (as, for example, has been the case in Victoria) occur simply as a component of an “aids and equipment program”, with eligibility for oxygen therapy being determined in the same way as for wheelchairs and walking aids. Oxygen therapy should be regarded as drug therapy, with regular follow-up and clinical review required after prescription and distribution. An explanation for the higher mortality rates in South Australian oxygen consumers, compared with those in France, could be the home care and review program that French patients receive, which may enhance their survival.8 The article by Serginson and colleagues in this issue of the Journal is very opportune,9 coming at a time when the National Health and Hospitals Reform Commission has highlighted the fragmentation of our health system, with its complex divisions of funding responsibilities and performance accountabilities between different levels of government.10 Serginson and colleagues show that there is considerable variability in prescription rates of oxygen, costs of oxygen therapy, and types of oxygen services provided across different Australian states and jurisdictions. The total direct cost of oxygen therapy in Australia in 2005, to treat a little over 20 000 Australians, was estimated by these authors to be $31 million. At the time of their audit, state government funding was not provided for portable oxygen therapy in Queensland and, in New South Wales, it was only available in some areas and for some patients. In New South Wales and Queensland, a means test was applied to determine eligibility for all types of oxygen therapy. Prescription rates were found to vary greatly, from 44 per 100 000 population in the Northern Territory to 133 per 100 000 in Tasmania. Explanations for the differences were not apparent from this important but retrospective observational study. Much work still needs to be done to determine who benefits from oxygen therapy and whether those Australians currently using oxygen — and the community, as a whole — are getting the best value they can from this treatment. Serginson and colleagues call for a national register of domiciliary oxygen therapy.9 Similar recommendations were made by the Australian Lung Foundation in their funding submission to Treasury in 2006.11 We endorse these recommendations wholeheartedly. A scheme to monitor variability in applying guidelines; the use of and adherence to oxygen therapy; and the costs and clinical outcomes of oxygen treatment — both mortality and morbidity — is overdue. Are the disappointingly poor survival data reported from South Australia reflective of survival data in other states? Scrutiny of costs and benefits in health care is currently on the agenda, and taxpayers have the right to expect that outcomes will be reviewed in a systematic way to ensure best practice. It will be important to involve consumers in such a process; we have very little qualitative data about how Australians using home oxygen feel about their treatment. The available qualitative research suggests patients may consider oxygen therapy a burden and adhere poorly to recommendations regarding its use.7 While we await the results of further studies examining the questions still to be answered about oxygen therapy, we should ensure that data about patients requiring oxygen in Australia are kept in a national home oxygen therapy registry, and that information regarding usage, adverse effects and outcomes is collected. This will enable prioritisation of resources and encourage high-quality research to inform future oxygen use.

Christine F McDonald MB BS(Hons), FRACP, PhD · Alan J Crockett PSM, MPH

The conference highlighted the need for new policy development using quantitative methods The Fourth Emerging Health Policy Research Conference was held at the Menzies Centre for Health Policy, University of Sydney, on 19 August 2009. This national gathering of “new and emerging” policy researchers came as the Rudd government’s commissions and taskforces delivered their recommendations on improving Australian health. The conference showcased a critical mass of diverse and innovative research projects that push the boundaries of traditional policy enquiry. Forty-two up-and-coming health policy researchers from Australia and New Zealand presented papers on an exciting range of topics within nine concurrent sessions. Researchers with expertise in the fields of medicine, anthropology, sociology, psychology, economics, nursing, history, law and political science exposed multiple disciplinary perspectives on critiquing and addressing current and future health policy problems.1 Hopes for substantial health reform around the world have been challenged by the global financial crisis. Professor John Wyn Owen (Chair of the Board of Governors, University of Wales Institute, Cardiff, and former Secretary of the Nuffield Trust, London), opened the conference with his keynote speech on the challenge to global health posed by macroeconomic emergencies. Health policy development requires an appreciation of the changing nature of capitalism and an assessment of the global health consequences of economic vulnerability. Although public awareness of the need for concerted action has never been higher, public health emergencies, from severe acute respiratory syndrome to swine flu, have weakened economies, lowering the resources that can be mobilised. Owen stressed the importance of the central discipline of health policy analysis — namely, understanding the context in which problems emerge, research is applied and political forces are mobilised. Christine Bennett (Chair, National Health and Hospitals Reform Commission, Canberra) also gave a spirited account of the principal recommendations of the National Health and Hospitals Reform Commission report.2 Major policy themesThree major policy themes emerged in the remainder of the conference: improving chronic illness prevention and management, the intersections between health and other sectoral policy, and new policy instruments. Improving chronic illness prevention and managementThe desperate need for health systems and preventive health initiatives to combat the growing epidemic of chronic disease was raised in several presentations. For example, Renee Slade (Research Officer, Diabetes Unit, University of Sydney) described a capacity development process that is critical to improving the care and management of type 2 diabetes in the Pacific Islands and could provide a useful model for similar settings. Elizabeth Dunford (PhD candidate, George Institute for International Health, Sydney) demonstrated that, although action to reduce salt in Australian foods is being taken up by industry, full buy-in by the Australian government is necessary for widespread adoption of this initiative. Intersections between health and other sectoral policyThe importance of developing cross-sectoral collaboration in developing and implementing policy to tackle challenging issues such as health equity and the social determinants of health also featured strongly in many presentations. The analysis by Emma Webster (DrPH candidate, Discipline of Public Health, Flinders University, Adelaide) of women’s decision making around disbursement of the Baby Bonus payment suggests that an unintended consequence of this social policy has been to entrench social distinction, undermining its effectiveness as a public health intervention. Mandy Nielson (PhD candidate, School of Social Work and Human Services, University of Queensland, Brisbane) pointed to a silent epidemic of chronic pain — much of which has little or no identifiable pathology — and argued that multidisciplinary “biopsychosocial” models need to take the “social” element more seriously. The integration of commonly siloed sectors was pushed further in an analysis by Remo Ostini (Senior Research Officer, Faculty of Health Sciences, University of Queensland, Brisbane) of the implications of low health literacy for illness management, arguing for a national health literacy strategy. Such a strategy would require collaboration between the health, education, housing, employment and welfare sectors to gain any traction. New policy instrumentsDeveloping effective strategies to allow researchers to better engage with and influence the policy process emerged as the final theme of the conference. For example, Mat Walton (PhD candidate and Research Fellow, Department of Public Health, University of Otago, Wellington, New Zealand) discussed his use of complexity theory to untangle the complex social systems that influence children’s nutrition and, in particular, how such findings could be applied to improve child nutrition policy in New Zealand. Gabriel Moore (Senior Project Officer, Sax Institute, Sydney) presented her proposal for a knowledge translation framework that integrates a pathway of interventions, including analysis of research need, development of policy–research partnerships, knowledge brokering, knowledge exchange and advocacy. Carol Holden (Chief Executive Officer, Andrology Australia, Monash University, Melbourne) looked at past failures to develop effective interventions in men’s health, identifying strength of stakeholder networks as the crucial variable and proposing a more strategic approach to health promotion. Methodology underpinning health policy researchMuch of the research presented was qualitative, reflecting interest in experiences of policy outcomes, broader factors influencing policy outcomes, and participatory policy development. Qualitative methods — mainly interviews with stakeholders such as industry representatives, youth and members of the wider community — were used to assess experiences of policy implementation and effectiveness, as well as to directly inform new policy development. Another method employed was linguistic analysis. For example, Denise Fry (Project Officer, Health Promotion Service, Sydney South West Area Health Service), outlined an analysis of the keywords used in health promotion, showing how language can shape and frame policy issues. This helps to explain the persistence of behaviourist models in health promotion, which focus on individual motivation and exclude broader concepts of social determination. Qualitative methods are influential as a policy tool as long as the findings are interpreted in a way that is sensitive to current and emerging policy opportunities. This point was reinforced by Tanisha Jowsey (Research Officer, Serious and Continuing Illness Policy and Practice Study, Australian National University, Canberra) in her presentation on how to translate qualitative findings into practical, relevant and feasible policy options to improve chronic illness management. The policy process was analysed to gain a better understanding of factors influencing policy uptake and implementation. For example, Kathy Flitcroft (Research Fellow, School of Public Health, University of Sydney) presented an analysis of the relative roles of research evidence and other factors in decision-making and implementation processes regarding bowel cancer screening. Similarly, qualitative methods such as ethnographic and historical research tools were used to analyse the broader context of health policy making and to investigate factors affecting policy implementation and equity issues, such as access to care. Many of the evaluations of policy outcomes used mixed methods research, combining data on measurable outcomes with interview data reflecting stakeholder experiences. The conference also highlighted the need for new policy development using quantitative methods, such as epidemiological studies, economic analyses of cost-effectiveness, randomised controlled trials and carefully evaluated policy experiments. Natalie Plant (Research Officer, Menzies Centre for Health Policy, University of Sydney) presented on the development of a randomised controlled trial to compare patient management strategies in coordinating the hospital and community care of patients with serious and chronic illnesses. The concluding speech was presented by Mary Ann O’Loughlin (Executive Councillor and Head of the Secretariat of the Council of Australian Governments [COAG] Reform Council), who described the COAG Health Reform Project, which has been largely forgotten amidst other more headline-grabbing commissions and reports. Recent COAG reforms will require annual report cards on the progress of state and territory governments and (in a break from the past) the federal government, measuring their progress in meeting targets on prevention, hospital and primary care reform, and Indigenous health. Australian policy researchers will have comprehensive data to compare the performance of governments and identify models to improve practice. The Emerging Health Policy Research Conference was convened in response to concerns about the limited research culture in Australian health policy.3 The 2009 conference saw a doubling of papers and attendance compared with the previous year, so the future is looking a bit brighter.

James Gillespie PhD · Beverley Essue BSc(Hons), MPH · Stephen R Leeder MD, PhD, FRACP · Anne Marie T Thow BScNutr(Hons), MPubPol

Objective: To develop a tool to allow Australian hospitals to monitor the range of hospital-acquired diagnoses coded in routine data in support of quality improvement efforts.Design and setting: Secondary analysis of abstracted inpatient records for all episodes in acute care hospitals in Victoria for the financial year 2005–06 (n = 2.032 million) to develop a classification system for hospital-acquired diagnoses; each record contains up to 40 diagnosis fields coded with the ICD-10-AM (International Classification of Diseases, 10th revision, Australian modification).Main outcome measure: The Classification of Hospital Acquired Diagnoses (CHADx) was developed by: analysing codes with a “complications” flag to identify high-volume code groups; assessing their salience through an iterative review by health information managers, patient safety researchers and clinicians; and developing principles to reduce double counting arising from coding standards.Results: The dataset included 126 940 inpatient episodes with any hospital-acquired diagnosis (complication rate, 6.25%). Records had a mean of three flagged diagnoses; including unflagged obstetric and neonatal codes, 514 371 diagnoses were available for analysis. Of these, 2.9% (14 898) were removed as comorbidities rather than complications, and another 118 640 were removed as redundant codes, leaving 380 833 diagnoses for grouping into CHADx classes. We used 4345 unique codes to characterise hospital-acquired conditions; in the final CHADx these were grouped into 144 detailed subclasses and 17 “roll-up” groups.Conclusions: Monitoring quality improvement requires timely hospital-onset data, regardless of causation or “preventability” of each complication. The CHADx uses routinely abstracted hospital diagnosis and condition-onset information about in-hospital complications. Use of this classification will allow hospitals to track monthly performance for any of the CHADx indicators, or to evaluate specific quality improvement projects.

Terri J Jackson PhD · Jude L Michel BHlthInfoManagement(Hons) · Rosemary F Roberts MPH, MBA · Christine M Jorm MD, PhD, FANZCA · John G Wakefield FRACMA, FACRRM, FRACGP

Objectives: To determine the rate of prescription of and government expenditure for domiciliary oxygen therapy (DOT) in Australia, and to identify interstate differences in rates, costs and service provision.Design: Retrospective observational study.Participants and setting: Government departments and health services (state and federal) that funded DOT in Australia in the 2004–05 financial year (including the Department of Veterans’ Affairs [DVA] and the Department of Health and Ageing [DoHA]).Main outcome measures: Prescription rates, cost of DOT in 2004–05, and services provided in each jurisdiction.Results: In 2005, 20 127 patients were using DOT, giving a national prevalence of 100 prescriptions per 100 000 population. The total cost was about $31 million. State governments, the DVA and the DoHA funded 13 899 (69%), 4084 (20%) and 2144 (11%) patients, respectively. Prescription rates varied threefold between the states, ranging from 44 (Northern Territory) to 133 (Tasmania) per 100 000 population. Cost per patient per year varied fourfold between the DVA and the DoHA. All jurisdictions funded oxygen according to the clinical criteria of the Thoracic Society of Australia and New Zealand, but considerable variability in service provision was identified.Conclusion: DOT prescription rates and costs vary considerably between jurisdictions. An urgently needed national DOT register would enable the current variability to be understood and allow service planning and benchmarking of clinical outcomes.

John G Serginson RN, BN, MCN · Ian A Yang MB BS(Hons), PhD, FRACP · John G Armstrong MB BS, PhD, FRACP · David M Cooper MB BS, MSc, FRACP · Anthony M Matthiesson MB BS, FRACP · Stephen C Morrison MB BChir, PhD, FRACP · Judy M Gair MHSc · Barbara Cooper MB BS, FRACMA, FRACGP · Paul V Zimmerman MB BS, MD, FRACP

The major problem of access block to acute hospital admissions in Australia needs a more radical response than a focus on increasing inpatient beds, as suggested recently. Australia needs to take on board recent changes in United Kingdom hospital systems, which have revolutionised patient flow during acute admissions and dramatically improved efficiency, clinical quality and outcomes. Accident and emergency departments in the UK became recognised as part of acute hospital dysfunction. Now, increasingly, patients needing admission are directed as soon as possible to an acute medical assessment and admission unit (AMAAU), thus freeing accident and emergency staff for re-defined core priorities. AMAAUs require supervision by a new style of acute general physician, who drives timely management of acute medical patients, defines patient needs, estimates the likely date of discharge, and selects the most appropriate inpatient clinical stream. These reforms are staff-intensive and expensive, but cost-effective and patient-focused. They highlight the need for an adequate scale for acute clinical services and defined streams of care within individual hospitals, as well as explicit networking at a regional level to guarantee specialist acute services when needed.

E Haydn Walters DM, FRCP, FRACP · David J Dawson MD, FRCP

To the Editor: Finally! An article in the Journal about health reform that carries no spin and decries further futile experimentation in management. Lewis and Leeder are to be congratulated on their insightful review.1 As they point out, social and environmental determinants of health are far more important to a community’s well-being. This was recognised intuitively as long ago as 1986, with the promulgation of the Ottawa charter,2 and its recommendation that health services be reoriented primarily toward promoting heath rather than delivering acute care per se. As Lewis and Leeder articulate, the evidence in favour of this line of thinking is actually quite potent.1 However, as they point out, the thing that surprises students and practitioners in public health is why the “bigger picture” has been so difficult to comprehend and act on. Rather than a need for the “stars to be aligned”, perhaps this is the time for stronger advocacy? And while we’re at it, evaluation tools for health promotion programs need to become more sophisticated if we’re going to convince our colleagues, politicians and the community that we’re spending their money wisely. The transformation that Lewis and Leeder recommend is likely generational in its span, but what better time to make a start?

George Larcos

Incorrect graph and wording: In “Avoidable hospitalisation in Aboriginal and non-Aboriginal people in the Northern Territory” in the 18 May 2009 issue of the Journal (Med J Aust 2009; 190: 532-536), there was an error in Box 4 (Li et al). In the panels headed “25–44 years” and “45 years and over”, the lines representing Aboriginal and non-Aboriginal rates were transposed. The correct version of Box 4 appears here. In addition, in the second paragraph of the results section, the wording was potentially misleading. The paragraph should have read: “Although total average avoidable hospitalisation rates were higher in Aboriginal than non-Aboriginal people in the NT, the largest differences were observed in the age groups 25–44 and 45–64 years (Box 1).” 4 Trends in age-adjusted, avoidable hospitalisation rates by Aboriginality and age group, Northern Territory, 1998–99 to 2005–06

Shu Q Li MPH, MB, BNursing · Natalie J Gray MIPH(Hons), MB BS(Hons), BSc/LLB(Hons) · Steve L Guthridge MB BS, MPH, FAFPHM · Sabine L M Pircher MPH, BNutrDiet

Objective: To review the outcomes of offering carrier testing for cystic fibrosis (CF) to couples considering pregnancy, and to women in early pregnancy and their partners.Methods: An after-hours clinic was established in Newcastle for discussion of issues related to prenatal testing. Couples were offered CF carrier testing by extracting DNA from a mouthwash sample. An expanded one-step model was used with both partners being tested initially for the p.F508del cystic fibrosis transmembrane conductance regulator gene (CFTR) mutation. If one partner was a p.F508del carrier, the other partner was tested for an additional 28 CFTR mutations.Results: Of 1000 individuals who were offered CF carrier testing, none declined. No re-collections of mouthwash samples were required, and results were available within 14 days. There were 730 individuals who had no family history of CF (73%); 27 were carriers (4%; 95% CI, 2.4%–5.3%), and there were two high-risk couples where both partners were carriers of p.F508del. There were 270 individuals who had an affected family member with CF or a child identified as a CF carrier through newborn screening; 126 were carriers (46%; 95% CI, 40.6%–52.8%), and there were two high-risk couples — one couple where both partners were carriers of p.F508del, and another couple where the woman was homozygous for p.F508del and the man was a p.F508del carrier. The information on carrier status led the four high-risk couples to change their reproductive decisions to avoid having a child with CF.Conclusion: CF carrier testing for couples using an expanded one-step model will detect about 80% of high-risk couples and enables various reproductive choices. We believe that all couples considering pregnancy, and women in early pregnancy and their partners, should be offered CF carrier testing.

Louise M Christie RN, CM, GradDipGenCouns · Angela J Ingrey BSc, GradDipGenCouns · Gillian M Turner MB ChB, DSc, FHGSA · Anne L Proos MSc · Gloria E Watts BSc, MSc

Objective: Design and setting: Prospective modelling with the tools FluSurge 2.0 and FluAid 2.0 (developed by the United States Centers for Disease Control and Prevention) over 12 weeks from when the pandemic “Contain” Phase was declared on 22 May 2009, compared with data obtained from daily hospital reports of pandemic (H1N1) 2009 influenza-related admissions and transfers to intensive care units (ICUs).Main outcome measures: The effect on hospitals as projected by the FluAid 2.0 model compared with observed hospital admissions and ICU admissions.Results: Prospective use of the FluAid 2.0 model provided valuable health intelligence for assessment and projection of hospitalisation and critical care demand through the first 10 weeks of the pandemic in Victoria. The observed rate of hospital admissions for pandemic (H1N1) 2009 was broadly consistent with a 5% gross clinical attack rate, with 0.3% of infected patients being hospitalised. Transfers to ICUs occurred at a rate of 20% of hospital admissions, and were associated with vulnerable patient groups, and severe respiratory failure in 82% of patients admitted to ICUs. Most patients treated in ICUs (85%) survived after an average ICU length of stay of 9 days (SD, 6.5 days). Mechanical ventilation was required by 72% of patients admitted to ICUs, and extracorporeal membrane oxygenation (ECMO) was used for 7%. Pre-existing haematological malignancy accounted for half of all the deaths in patients admitted to ICUs with pandemic (H1N1) 2009 influenza.Conclusions: Prospective use of modelling tools informed critical decisions in the planning and management of the pandemic. Early estimation of the clinical attack rate, hospitalisation rates, and demand for ICU beds guided implementation of surge capacity. ECMO emerged as an important treatment modality for pandemic (H1N1) 2009 influenza, and will be an important consideration for future pandemic planning.

Martin E Lum MB ChB, FANZCA, MBA(Exec) · Alison J McMillan CCN, BEd, MBA · Chris W Brook FRACP, FAFPHM, FRACMA · Rosemary Lester MPH, MS(Epid), FAFPHM · Leonard S Piers MD, PhD, MPH

Patient contact with medical students and clinicians may be on the decline. Increasing medical graduate numbers, workforce and training demands, and the institution of safe working hours are putting pressure on opportunities for direct clinical interaction. Medical education curricula and clinical postgraduate education supervisors must ensure that students and junior doctors recognise the importance of hands-on clinical contact with patients. Although many new developments aid health care efficiencies and can assist with the complexities of care required in a modern hospital, clinicians need to maintain their focus on the patient.

Bill Lancashire MB BS, FRACGP, CCFP · Craig T Hore MB BS, FACEM, FJFICM · Robert G Fassett MB BS, PhD, FRACP

Improving hand hygiene practices in health care has been a major challenge for more than 160 years.1 Despite much evidence that hand hygiene practices are effective in preventing infection and reducing the spread of microbial resistance, the hand-cleaning behaviour of health care workers (HCWs) remains largely unchanged.2 Indeed, in almost all settings where it has been assessed, compliance with hand hygiene practices at appropriate times during the course of patient care has been less than 50%. But should HCWs carry all the blame? How do working conditions affect hand hygiene behaviour? Can behaviour change? If so, how much change in individual behaviour is necessary to reflect change at a group level? Is a major system change sufficient to transform practices? Is hand hygiene behaviour integrated into the theory of ecological perspective3 once change is targeted? What should the targets for improvement be? How far can HCWs be expected to modify their practices? How long will it take to succeed? How can behavioural change be sustained, if and when it is achieved? What does “success” mean in terms of hand hygiene promotion? What are the best indicators of success? How much local success is needed to predict more global achievements? These are some of the many questions to be kept in mind by all those embarking on hand hygiene promotion. Successful promotion is a crusade, and we should not forget the “first crusader”, Ignaz Semmelweis, who paved the way in 1847.1 Semmelweis’s crusade was long and difficult and, although extremely beneficial to patient safety, it was certainly not rewarding for him, and was even detrimental to his career.4 But attitudes and evidence have changed over the past 162 years. Thankfully, it is now well established that successful hand hygiene promotion does not result from forcing HCWs to plunge their hands into a caustic, chlorinated lime solution before patient contact and accusing them of being murderers if they refuse! Ample evidence suggests that successful hand hygiene promotion is the result of multimodal strategies involving multiple partners and key players.2 The proposed, tested and validated World Health Organization strategy now used in many hospitals worldwide (Box 1) includes at least five key elements: homogeneous HCW education; performance monitoring and feedback; reminders in the workplace; facilitated access to alcohol-based hand rub (AHR) at the point of patient care; and promotion of a safety culture at all levels.2,5 This strategy has been modelled on previous longstanding experience at the University of Geneva hospitals6,7 before being adopted at single8,9 and multiple institutions10,11 and, importantly, adapted to different cultures for worldwide use in both developed and developing countries.12,13 Clean hands save lives is a good example of a statewide multimodal promotion campaign. The strategy included monitoring of HCWs’ compliance, with performance feedback; using staff “champions” and local leaders; placing reminders in the workplace; engaging patients and their families; and ensuring the availability of AHR at the point of care. This supplement includes four reports that summarise important aspects of the project’s management and present early results relating to structures, processes and outcomes.14-17 System change has been one of the first measurable, successful achievements of the Clean hands save lives campaign. Over a period of less than 6 months, the availability of AHR at the point of care improved markedly, to the point where 70% of all available hospital beds in New South Wales had at least one AHR dispenser nearby. Importantly, such a system change must be sustainable, with a measurable increase in AHR use over time.6,7 System change implies culture change.18,19 Pre- and post-campaign surveys showed that the NSW campaign significantly raised HCWs’ awareness of hand hygiene and improved their perceptions of the need for the campaign and of its ability to help improve their own practices. Most HCWs believed that they could sustain system and behavioural change over time, and some even gained sufficient confidence to remind their peers. Furthermore, a quarter of surveyed patients and hospital visitors said they would be willing to actively participate in hand hygiene promotion by reminding staff about hand hygiene. Thus, the Clean hands save lives campaign clearly initiated a culture change at an organisational6,20 and possibly regional level. It helped to promote positive attitudes and dispel negative perceptions held by staff, patients, and visitors. Whether such a change has been sufficiently embedded in health care organisations at all levels to induce individual and institutional accountability remains to be evaluated in the near future. Among the campaign’s process and outcome measures were compliance with hand hygiene practices and monitoring of methicillin-resistant Staphylococcus aureus (MRSA) cross-transmission and infection rates. Overall hand hygiene compliance, monitored before and after patient contact, improved from 47% to an average of 61%, and all categories of HCW except medical staff improved their compliance. As universally reported,2,6,8-13,18-20 compliance after patient contact was markedly better than before patient contact, emphasising the need for further education to improve patient safety. Preventing pathogen transmission to patients relies above all on cleaning hands before touching each patient, before performing clean and aseptic tasks,21,22 after contact with a patient or the patient’s close environment, or after exposure to body fluids. Respecting these recommendations will mostly protect HCWs and patients and prevent environmental contamination (Box 2). Whether the observed improvement in hand hygiene compliance between the pre- and post-campaign periods may have been partly due to a Hawthorne effect is debatable. However, such an effect need not be considered an undesirable outcome if it contributes to positive culture change. Although improvement in hand hygiene practice was paralleled with some measurable reductions in indicators of MRSA infection, the effect of major confounders should be recognised, particularly in the context of statewide surveillance and interventions. In summary, the Clean hands save lives campaign has achieved remarkable success in NSW health care institutions — system change, culture change and practice improvement, with early signs of an impact on some patient safety indicators. Ensuring the sustainability of the campaign, together with organisational and regional changes to foster accountability at different levels, will be challenging. Further improvement will require HCWs to integrate the “My five moments for hand hygiene” concept (Box 2)22 into their thinking and routine behaviour and thus shift the focus towards greater patient safety. Further development of the concept of staff champions and local leaders to drive compliance improvement among all HCWs, particularly medical staff, is critical.23 Importantly, all health care institutions in NSW need to adopt the Clean hands save lives strategy. Successful diffusion of innovation and change requires adaptation.2,18,24 Campaign strategists and crusaders need to understand that having the support of management can be extremely helpful in making a campaign more cost-effective. Adaptation of tools and interventions to local needs is critical for universal endorsement, sustainability and long-term success. Combining the efforts and successes of the NSW campaign with the statewide campaign in Victoria10 would be a positive move towards the future roll-out of national action in Australia, and would follow the example of more than 40 campaigning countries worldwide.25,26 Long live the Clean hands save lives crusade and its army of crusaders and numerous descendants. We’ll remind you again in 162 years. 1 Health care institutions that have endorsed the World Health Organization’s multimodal hand hygiene promotion strategy* * As at May 2009. 2 “My 5 moments for hand hygiene”* * Adapted from Sax et al.22

Didier Pittet MD, MS

Objective: To describe the planning and execution of a statewide campaign aimed at improving compliance with hand hygiene practices in New South Wales public hospitals.Design and setting: The campaign was conducted in all area health services (AHSs) in NSW (covering 208 public hospitals) between February 2006 and February 2007. Clinical practice improvement methods and campaign strategies were used to improve the availability and use of alcohol-based hand rub (AHR) at the point of patient care, using staff champions and local leaders, engaging patients and families, and measuring compliance. Staff were given regular feedback on their performance. Project officers funded by the Clinical Excellence Commission (CEC) provided local project management support and implemented the campaign in a standardised format orchestrated by the CEC.Main outcome measures: Proportion of available beds with secured and unsecured AHR containers nearby; amount of AHR used (based on purchasing patterns).Results: Hospital visits before the campaign identified a lack of appropriately placed AHR at the point of care. The number of AHR containers per available bed in near-patient locations increased to 13 280/18 951 (70%) after the campaign. The quantity of AHR purchased per month across NSW public hospitals increased from 1477 L to 5568 L (a 377% increase).Conclusion: The CEC was successful in systematising the placement of AHR in all NSW public hospitals at the point of patient care. Although the use of AHR increased substantially, some staff were resistant to changing their hand hygiene practices.

Annette C Pantle MB BS, MPH, FRACMA · Kimberley R Fitzpatrick BHSM · Mary-Louise McLaws DipTropPublHlth, MPH, PhD · Clifford F Hughes MB BS, FRACS, FACS

Objective: To present the results of surveys of staff, patients and visitors about their perceptions of hand hygiene behaviour before and after implementation of the Clean hands save lives campaign in New South Wales public hospitals.Design and setting: Pre- and post-campaign questionnaires, disseminated through project officers in each health authority, were completed by selected staff and patients/visitors in all 208 public hospitals in NSW. Combined, de-identified results for each health authority were forwarded to the NSW Clinical Excellence Commission for analysis.Main outcome measures: Awareness of campaign material; staff perceptions about their ability to maintain a high level of hand hygiene compliance before and after contact with patients; compliance self-reported by staff compared with compliance perceived by patients/visitors and compliance assessed by overt observation.Results: Most staff and patients/visitors were aware of campaign materials. Eighty-six per cent of staff respondents (495/578) believed that placement of alcohol-based hand rub (AHR) close to the point of patient care had improved hand hygiene compliance, and 76% (510/671) believed they could sustain their level of compliance. Only 1 in 4 patients or visitors (106/397) were willing to question health care workers who appeared not to be complying with hand hygiene practices.Conclusion: As the first coordinated statewide campaign to modify hand hygiene culture, the Clean hands save lives campaign successfully engendered positive attitudes and dispelled negative perceptions about the onerous nature of before- and after-patient-contact hand hygiene compliance.

Kimberley R Fitzpatrick BHSM · Annette C Pantle MB BS, MPH, FRACMA · Mary-Louise McLaws DipTropPublHlth, MPH, PhD · Clifford F Hughes MB BS, FRACS, FACS

Objective: To describe improvements in hand hygiene compliance after a statewide hand hygiene campaign conducted in New South Wales public hospitals.Design and setting: The campaign was conducted in all area health services in NSW (covering all 208 public hospitals). Alcohol-based hand rub (AHR) was introduced into all hospitals between March and June 2006. In each hospital, five overt observation surveys of hand hygiene compliance by health care workers (HCWs) were conducted: one pre-implementation survey and four post-implementation surveys (in August 2006, November 2006, February 2007 and July 2008).Main outcome measures: Overtly observed hand hygiene compliance rates by HCWs, stratified by before- and after-patient contact, Fulkerson’s contact risk categories, and four health care professional groupings.Results: The overall hand hygiene compliance rate improved from 47% before the intervention to an average of 61% over the last three observation periods (P < 0.001). All professional groups sustained improved compliance rates except medical staff, whose practices reverted to pre-intervention rates. Nursing staff maintained significantly improved compliance, with an average rate of 67% after the intervention. Overall hand hygiene compliance before patient contact improved from 39% (pre-campaign) to 52% (July 2008) (P < 0.001). Overall compliance after patient contact improved from 57% to 64% (P < 0.001) over the same period. Compliance associated with medium-risk contacts increased from an average of 51% in the first two observation periods to an average of 62% over the last three observation periods (P < 0.001). The corresponding compliance rates associated with low-risk contacts were 35% and 56%, respectively (P < 0.001).Conclusion: An overall improvement in hand hygiene rates was achieved with the introduction of AHR. Increased adherence to before-patient contact compliance, especially by nursing staff, contributed to the progress made, but an acceptable overall level of hand hygiene practice is yet to be achieved. It is now time to focus on a long-term behavioural change program directed specifically at medical staff.

Mary-Louise McLaws DipTropPublHlth, MPH, PhD · Annette C Pantle MB BS, MPH, FRACMA · Kimberley R Fitzpatrick BHSM · Clifford F Hughes MB BS, FRACS, FACS

Objective: To examine whether improved hand hygiene compliance in health care workers after a statewide hand hygiene campaign in New South Wales hospitals was associated with a fall in rates of infection with multiresistant organisms.Design and setting: Data on rates of new methicillin-resistant Staphylococcus aureus (MRSA) infections (expressed as four clinical indicators) are reported by some Australian hospitals to the Australian Council on Healthcare Standards (ACHS) for accreditation purposes and are mandatorily reported by all NSW hospitals to the NSW Department of Health. Infections are classified according to whether they are acquired in the intensive care unit (ICU) or other wards and whether they are from sterile sites (blood cultures) or non-sterile sites. The clinical indicators reflect four different site categories (ICU sterile site, ICU non-sterile site, non-ICU sterile site and non-ICU non-sterile site) and are expressed as the number of new health care-associated infections per 10 000 acute care bed-days. Clinical indicator rates were examined for any decline between the pre-campaign period (July–December 2005) and post-campaign period (January–July 2007), and were compared with trends over a similar period in states without a hand hygiene campaign.Main outcome measures: Pre-campaign and post-campaign rates for four MRSA clinical indicators.Results: Between the pre- and post-campaign periods, there was a 25% fall in MRSA non-ICU sterile site infections, from 0.60/10 000 bed-days to 0.45/10 000 bed-days (P = 0.027), and a 16% fall in ICU non-sterile site infections, from 36.36/10 000 bed-days to 30.43/10 000 bed-days (P = 0.037). The pre- and post-campaign rates of MRSA infection from ICU sterile sites (5.28/10 000 bed-days v 4.80/10 000 bed-days; P = 0.664) and non-ICU non-sterile sites (5.92/10 000 bed-days v 5.66/10 000 bed-days; P = 0.207) remained stable. Australia-wide MRSA data reported to the ACHS showed a 45% decline in infections from ICU non-sterile sites, from 25.89/10 000 bed-days to 14.30/10 000 bed-days (P < 0.001), and a 46% decline in infections from non-ICU non-sterile sites, from 3.70/10 000 bed-days to 1.99/10 000 bed-days (P < 0.001) over the period 2005–2006.Conclusion: Two out of four clinical indicators of MRSA infection remained unchanged despite significant improvements in hand hygiene compliance in NSW hospitals. The reduction in MRSA infections from ICU non-sterile sites in NSW hospitals was mirrored in ACHS data for other Australian states and cannot be assumed to be the result of improved hand hygiene compliance. Concurrent clinical and infection control practices possibly influence MRSA infection rates and may modify the effects of hand hygiene compliance. More sensitive measurements of hand hygiene compliance are needed.

Mary-Louise McLaws DipTropPublHlth, MPH, PhD · Annette C Pantle MB BS, MPH, FRACMA · Kimberley R Fitzpatrick BHSM · Clifford F Hughes MB BS, FRACS, FACS