Health services administration

Objective: To project the future size of the Australian medical workforce, from 2001 to 2012.Design and setting: Stochastic simulation modelling of the Australian medical workforce, taking into account recent increases in medical school capacity and trends in the intake of foreign graduates.Main outcome measures: Number of full-time equivalent (FTE) medical practitioners per 100 000 persons within various occupation groups from 2001 (baseline) to 2012.Results: The total medical workforce was projected to rise from 53 384 in 2001 to 67 659 by 2012 (95% CI, 63 924–71 036). On a per capita basis, the number of FTE clinicians was projected to rise from 331 per 100 000 persons in 2001 to 382 (95% CI, 359–403) per 100 000 persons in 2012. The general practice workforce was projected to fall from 133 FTE general practitioners per 100 000 persons in 2001, to 129 per 100 000 persons in 2003, and then remain at around this level through to 2012. The specialist workforce was projected to show steady growth, rising from 162 FTE specialists per 100 000 persons in 2001 to 206 (95% CI, 194–218) per 100 000 persons in 2012.Conclusions: The general practice workforce is likely to face continued chronic shortages, necessitating innovative policy responses to ensure that the community’s need for primary medical care is met. Retirement rates are a key determinant of workforce supply, suggesting a need to encourage general practitioners to remain active as long as they remain effective. Further refinement of stochastic models will help facilitate a more proactive approach to workforce planning.

Catherine M Joyce BA(Hons), MPsych, PhD · John J McNeil PhD, FRACP, FAFPHM · Johannes U Stoelwinder MD, FRACMA, FACHSE

As the Australian university sector awaits final decisions about the introduction and stipulations of a research quality framework (RQF), to assess the quality and impact of research, we have studied international commentary on the value of such exercises. This suggests there is little hard evidence to recommend the proposed RQF. The UK government led the field in 1986 with its research assessment exercise (RAE), which is widely believed to have compromised clinical academic medicine by failing to satisfactorily acknowledge the contribution of clinical academics, not only to research but also to teaching and clinical practice. After the 2008 RAE, the UK government will move to a simpler, metrics-based system for assessing research quality and allocating funding. The New Zealand Performance Based Review Fund (PBRF), introduced in 2003, is based on a combination of peer review and performance indicators. Several concerns have been raised; among them is the real cost–benefit ratio of participation, with reports that many universities have spent more on the exercise than they will gain in funding increases. The scoring system has received the most criticism and, after the partial round assessment scheduled for this year, the controversial unit of assessment will be reviewed. It might be more cost-effective for Australia to modify existing research assessment processes than to undertake a potentially costly and arduous exercise.

Louise G Shewan BA(Hons), PhD · Andrew J S Coats DM, DSc, FRACP

To the Editor: Healthy ageing is listed as a National Research Priority by the Australian Government. The higher prevalence of sensory, cognitive and mobility impairments in older people presents a major challenge in achieving this goal. The effects of single impairments are recognised,1,2 but the cumulative effects of multiple impairments have not been reported from population-based samples. We aimed to assess the impact of multiple impairments (vision, hearing, cognitive, mobility) on health-related quality of life (HRQOL), hospitalisation, and aged-care service use in an older Australian population. In the second cross-sectional Blue Mountains Eye Study,3 HRQOL was measured by means of the self-administered Short Form 36-item Health Survey (SF-36)4 (n = 3509; mean age, 66.7 years; 57% women). Visual impairment was defined as best-corrected visual acuity (after refraction) of less than 6/12 (better eye). Hearing impairment was defined as average hearing threshold (pure-tone air conduction, frequencies 500–4000 Hz) over 25 decibels (better ear). Possible cognitive impairment was defined as Mini Mental State Examination scores less than 24/30. Mobility impairment was recorded. General linear regression was used to calculate age-adjusted SF-36 mean scores,5 and logistic regression was used to estimate likelihood ratios for use of health and aged-care services. Models were age-adjusted to eliminate confounding. For 2873 participants who had completed the SF-36 (90.9%), the mean physical component score (PCS) was 44.9 (95% CI, 44.5–45.3) and the mean mental component score (MCS) was 51.9 (95% CI, 51.5–52.2). Age was significantly associated with the prevalence of these impairments (P < 0.001). After adjusting for age, people with any of the impairments had poorer mean PCS and MCS than those without the impairment (Box 1). Hospitalisation within the last year was reported by 743 participants (23.5%; 58.3% women), and 97 (3.1%; 65.0% women) reported regular use of community support services. Use of community support services was reported more frequently by people with any impairment, except possible cognitive impairment (Box 1). The presence of two or more impairments was associated with a cumulative, linear decline in HRQOL (Box 2). The successive addition of each impairment was associated with a decrease of 4.0 in mean PCS and 2.1 in mean MCS, and with greatly increased reporting of regular community support service use. The likelihood of participating in or completing the SF-36 decreased with increasing number of impairments. Hence, the prevalence of impairments and the extent of detrimental impacts on HRQOL may be underestimated. Nevertheless, our data highlight a linear increasing pattern of cumulative effects from multiple impairments on HRQOL, hospitalisation, and use of aged-care services. Preventing and reducing these impairments is crucial in maximising healthy ageing. 1 Prevalence, mean SF-36 physical and mental component scores, and use of services by impairment Impairments Prevalence (%) Age-adjusted mean SF-36 scores (95% CI) Use of services: %, age-adjusted and sex-adjusted odds ratio (95% CI) Physical component score Mental component score Hospitalisation in past 12 months Regular use of community services Visual impairment 2.7 42.8 (39.9–45.7) 47.6 (44.8–50.3)* 34.9%, 1.3 (0.8–2.2) 24.2%, 2.9 (1.4–6.0) Hearing impairment 33.4 43.8 (43.0–44.7)* 51.1 (50.3–51.9)* 27.5%, 1.1 (0.9–1.3) 7.4%, 2.7 (1.4–5.0) Cognitive impairment 2.2 42.2 (39.5–44.8)* 46.0 (43.4–48.5)* 28.2%, 1.0 (0.6–1.6) 14.1%, 1.7 (0.8–3.7) Mobility impairment 7.6 32.3 (30.8–33.7)* 48.1 (46.7–49.5)* 41.0%, 2.0 (1.5–2.7) 21.3%, 6.8 (4.2–11.0) All mean values adjusted to 66.7 years, the overall sample mean age. SF-36 = Short Form 36-item Health Survey.4 * Significantly lower than without disability. 2 Mean physical and mental component scores and use of services by increasing number of impairments No. of impairments* Age-adjusted mean SF-36 scores (95% CI) Use of services: %, age-adjusted and sex-adjusted odds ratio (95% CI) Physical component score Mental component score Hospitalisation in past 12 months Regular use of community services 0 (n = 1031) 46.6 (45.9–47.2) 52.8 (52.6–53.8) 22.0%, 1.0 0.4%, 1.0 1 (n = 616) 42.6 (41.8–43.3) 51.0 (50.3–51.7) 25.3%, 1.1 (0.8–1.3) 4.2%, 7.4 (2.7–19.8) 2 (n = 121) 38.6 (37.1–40.0) 48.8 (47.4–50.2) 35.5%, 1.5 (1.0–2.3) 19.0%, 24.9 (8.5–73.2) ≥ 3 (n = 31) 34.5 (32.2–36.8) 46.6 (44.5–48.8) 45.2%, 2.0 (0.9–4.1) 41.9%, 47.4 (13.1–171.4) SF-36 = Short Form 36-item Health Survey.4 * Includes vision, hearing, cognitive and mobility impairments.

Ee-Munn Chia · Jie Jin Wang · Elena Rochtchina · Paul Mitchell

Objective: To describe how high-cost users of inpatient care in Western Australia differ from other users in age, health problems and resource use.Design and data sources: Secondary analysis of hospital data and linked mortality data from the WA Data Linkage System for 2002, with cost data from the National Hospital Cost Data Collection (2001–02 financial year).Outcome measures: Comparison of high-cost users and other users of inpatient care in terms of age, health profile (major diagnostic category) and resource use (annualised costs, separations and bed days).Results: Older high-cost users (≥ 65 years) were not more expensive to treat than younger high-cost users (at the patient level), but were costlier as a group overall because of their disproportionate representation (n = 8466; 55.9%). Chronic stable and unstable conditions were a key feature of high-cost users, and included end stage renal disease, angina, depression and secondary malignant neoplasms. High-cost users accounted for 38% of both inpatient costs and inpatient days, and 26% of inpatient separations.Conclusion: Ageing of the population is associated with an increase in the proportion of high-cost users of inpatient care. High costs appear to be needs-driven. Constraining high-cost inpatient use requires more focus on preventing the onset and progression of chronic disease, and reducing surgical complications and injuries in vulnerable groups.

Janine Calver PhD · Kate J Brameld PhD · David B Preen PhD · Stoney J Alexia BA(Hons) · Duncan P Boldy MSc, PhD · Kieran A McCaul MPH

Staphylococcus aureus bloodstream (SAB) infections are common and serious causes of morbidity and mortality that incur considerable health care costs and are potentially preventable. It should be relatively easy for hospitals to collect data on the incidence of SAB episodes, to determine whether infections were acquired in hospital or in the community, and to establish whether they were health care associated. The proportion of SAB infections caused by methicillin-resistant S. aureus strains should be a useful indicator of the level of control of antibiotic resistance in the community and in the health care setting. Continuous monitoring of infection incidence would enable health care facilities to determine the effectiveness of interventions designed to minimise SAB infections.

Peter J Collignon FRACP, FRCPA, FASM · Irene J Wilkinson BSc(Hons), MPH, MASM · Gwendolyn L Gilbert MD, FRACP, FRCPA · M Lindsay Grayson MD, FRACP, FAFPHM · R Michael Whitby FRACP, FRCPA

Government-subsidised access to effective medicines in Australia is provided via the Pharmaceutical Benefits Scheme (PBS). Decisions to subsidise medicines are based on assessment of cost-effectiveness (“value for money”) by the Pharmaceutical Benefits Advisory Committee (PBAC).1 In effect, the PBS is “purchasing” health outcomes. As the majority of medicine use is publicly funded via the PBS, there is an obligation to monitor the outcomes to determine whether the expected health improvements are actually realised. Monitoring the outcomes of medicine use is a core component of the National Strategy for Quality Use of Medicines,2 a pillar of Australia’s National Medicines Policy. Review of the cost-effectiveness of subsidised medicines is also an initiative of the federal government.3 The Drug Utilisation Sub-Committee advises the PBAC on patterns and changes of drug use associated with subsidy restrictions. However, there is minimal evaluation of health outcomes. This article discusses the problem of accessibility to data needed to examine the outcomes and use of high-cost medicines in Australia. Targeting access to high-cost medicinesThe PBS has complex controls to ensure cost-effective use of high-cost medicines by targeting access to subsets of patients. PBS restrictions are based on evidence and a collaborative effort between the PBAC, the respective pharmaceutical companies and representative medical specialists.4 Patients must meet criteria for both starting therapy (severe disease inadequately controlled by existing cheaper treatments) and continuing therapy (substantial clinical improvement). Prescribers must provide documentation to support patients’ eligibility. The eligibility of individual patients for initiating or continuing treatment is assessed by Medicare Australia (previously the Health Insurance Commission), which administers the PBS and other health programs. PBS restrictions thus enforce monitoring and documentation of patients’ clinical outcomes from using specialised drugs such as imatinib for treating chronic myeloid leukaemia, and infliximab and etanercept for treating ankylosing spondylitis. Accessibility to data on the use of biological disease-modifying antirheumatic drugs (bDMARDs: etanercept, infliximab, adalimumab, and anakinra) for treating rheumatoid arthritis provides an illustrative example to raise important issues. Information on the clinical status of each patient that is required as part of an application for bDMARDs (Box 1) could be helpful in evaluating the long-term efficacy and safety of the medicines as well as determining the effectiveness, utility and appropriateness of targeted access schemes. The following are examples of questions that could be answered by researchers with access to such information: What are the health outcomes of patients who have commenced, continued, switched between, or withdrawn from biological treatments? What are the associations between use of biological agents and rheumatoid factor status, disease duration, and conventional antirheumatic drugs usage, and are they predictive of patient response? How many rheumatoid-factor-negative patients have been approved to commence biological treatment since the removal of rheumatoid-factor-positive status as an eligibility criterion? How does the cost of these medicines compare with the cost savings in other health programs? Data available on medicine use and health outcomesMedicare Australia maintains electronic databases of claims from pharmacies for subsidised medicines. The databases also store details of “authority prescription” requests and reimbursements (Box 2, A). These data are potentially accessible at both aggregated and de-identified individual level, including the related prescription claims (medicine usage profile). Requests for access to the data for legitimate research can be made, but the process is slow and difficult. Monthly aggregated prescription volume and expenditure statistics on each PBS item are available in the public domain through Medicare Australia’s website (Box 2, B). While these aggregated data provide some indication of the uptake of bDMARDs,5 the actual number of patients using a bDMARD can only be approximated (eg, a crude approximation was that more than 2000 patients had been commenced on bDMARDs by March 2005).6 However, the proportion of patients that was approved to continue these medicines cannot be determined. It is also not possible to examine the effects of the “interchangeability rule”, which allows eligible patients to switch between different bDMARDs — an important initiative under the PBS. We recognise that the primary responsibility of Medicare Australia is to deliver government health programs. On the other hand, its role as a major information source to assist effective health decision making is becoming increasingly apparent.7 The limited usefulness of currently accessible administrative data has been discussed previously.8 Our further concern, in the case of high-cost medicines, is that invaluable health information on each individual patient submitted to Medicare Australia (Box 1) is not captured in its electronic databases and is, therefore, inaccessible for research purposes. Unfortunately, the information on individual clinical status is regarded as merely supportive of a patient’s eligibility for access to high-cost medicines. The existing Medicare Australia databases only capture the “standard” information from an authority prescription (Box 2, A). The value of the clinical information is recognised by Medicare Australia, to the extent that some of this information is recorded manually in an Excel spreadsheet. However, these data do not comply with Medicare Australia’s own validated procedures and are not released because the reliability, accuracy and quality of the data are not controlled. This information, which is also required by Medicare Australia’s Program Review Division for auditing prescribers, is apparently just as difficult for the Division to obtain. Data on the use of high-cost medicines managed under the Highly Specialised Drugs Program (eg, infliximab, imatinib) are accessible on request through the Pharmaceutical Access and Quality Branch of the Australian Department of Health and Ageing — but, again, data on health outcomes are unavailable. A recent review of the extent to which information from the PBS and Medicare claims databases can be linked9 is a welcome step towards better monitoring of the use of medicines and informing health policies, as well as identifying possible risks and health outcomes resulting from their use. Comprehensive and comparable datasets on drug usage, clinical details and health outcomes are held by the Department of Veterans’ Affairs. The ability to link de-identified datasets is an encouraging example of what can be achieved. These datasets could be used to examine the outcomes of taking specific medicines. However, the uptake of bDMARDs in this special population is low, thereby limiting the usefulness of the data for this drug group. The Department of Health and Ageing, which holds de-identified data from PBS and Medicare claims and performs policy and program review, could provide useful feedback to prescribers and patients to enhance patient management. In an attempt to complement the minimal information available through Medicare Australia, rheumatologists have established a voluntary database (the Australian Rheumatology Association Database) to track patient outcomes. However, only about 35% of patients treated with bDMARDs are registered, which may partly reflect the additional administrative burden on practitioners of reporting this information. Some patients do not participate because of the regular questionnaires required and privacy concerns. This emphasises the need for public discussion to address concerns about privacy and to highlight the value of health outcomes research. The way forward: a need for better access to comprehensive dataEvaluation of drug use and health outcomes can provide important evidence of the effectiveness of medicines in the “real world”, where many factors affect the outcome other than the medicines themselves. Analyses of international health outcome data from large observational databases are useful. However, patients treated with high-cost medicines in Australia are likely to have more severe disease than patients treated with these medicines in other countries, as a result of our generally more restrictive criteria. Therefore, it is important to be able to separately analyse the health outcomes of the Australian patient population. External, independent examination of the PBS system of access to high-cost medicines from the perspective of system improvement, clinical outcomes or cost-effectiveness is currently impossible. Allowing sufficient access to information that is already collected on drug use and health outcomes should be the basis for improving the quality of the system. We consider that a review and enhancement of Medicare Australia databases, with liberalisation of access to administrative data for approved research, is essential if we are to increase the accountability, transparency, and efficiency of allocating public resources for pharmaceuticals. It would also enhance community confidence in the PBAC’s decisions. Better access to accurate, comprehensive and reliable measures of the value of pharmaceutical expenditure and health gains obtained are urgently needed in the interests of better health for all Australians. 1 Information required by Medicare Australia For initiating bDMARD therapy Patient’s Medicare number, name, and dates of previous biological treatment History of trialled disease-modifying antirheumatic drugs (name, dosage, duration, reasons for treatment withdrawal) Levels of inflammatory markers: erythrocyte sedimentation rate, C-reactive protein “Active joint” counts (any joints that are swollen and tender are indicated on a diagram) For continuing bDMARD therapy Patient’s Medicare number, name, and dates of previous biological treatment Baseline and current levels of inflammatory markers: erythrocyte sedimentation rate, C-reactive protein Reduction of “active joint” count (any joints still swollen and tender are indicated on a diagram) bDMARD = biological disease-modifying antirheumatic drug. 2 Administrative data currently available from Medicare Australia A. Records related to “authority prescription” requests and claims De-identified-patient identifier PBS code, generic/brand name and strength of item Date authority lodged with Medicare Australia Prescriber unique identifier Dosage and quantity Number of repeats Authority reason (eg, “authority only drug”/increased quantity/increased repeats) Authority assessment outcome (approved/rejected/pending) Officer initials State or territory Approval number Date of approval Whether original prescription has been supplied Pharmacy identifier Date of claim Claim identifier Whether the claim is for an original or repeat prescription Cost reimbursed Payment category (general, concession, entitlement) B. Statistical reports* Prescription counts by item Cost reimbursed by PBS/RPBS Monthly aggregated data (for each state and territory) Aggregated data by patient category (general, concession, entitlement) PBS = Pharmaceutical Benefits Scheme. RPBS = Repatriation Pharmaceutical Benefits Scheme. * Available at the Medicare Australia website (http://www.medicareaustralia.gov.au/providers/health_statistics/statistical_reporting.htm).

Christine Y Lu MSc · Kenneth M Williams PhD · Richard O Day MD, FRACP

Objective: To determine the psychological wellbeing of sole mothers in Australia.Design: Cross-sectional analyses of survey data from The Australian Longitudinal Study on Women’s Health.Participants: 9689 younger women (aged 22–27 years) surveyed in 2000 and 12 338 mid-age women (aged 47–52 years) surveyed in 1998.Main outcome measures: Demographic characteristics and economic status; prevalence of suicidal thoughts, self-harm, and psychoactive medication use; depression (Center for Epidemiologic Studies Depression Scale) and psychological health (the Mental Health Component Score of the Medical Outcome Short Form Health Survey [SF-36]).Results: Among the younger women, sole mothers were more likely than other women to have experienced suicidal thoughts (odds ratio [OR], 2.18; 95% CI, 1.45–3.27) and self-harm (OR, 3.25; 95% CI, 1.97–5.38). Among the younger and mid-age women, sole mothers were the group most likely to have used medication for depression (ORs, 2.75 [95% CI, 1.76–4.30] and 2.29 [95% CI, 1.56–3.37], respectively). They were more than twice as likely to have experienced depression, and had significantly poorer psychological health (P < 0.001). After adjusting for economic status, only depression and psychological health remained significantly associated with sole motherhood, and the strength of these relationships was reduced.Conclusions: Economic status partly accounts for the relatively poorer psychological health of sole mothers. Sole mothers are more likely than other women to experience debilitating psychological health problems.

Deborah Loxton PhD, BPsych(Hons) · Rosemary Mooney BA(Hons) · Anne F Young PhD, AStat

Objective: To describe the implementation of a nurse-led preoperative cataract assessment and postoperative care clinic and to assess the safety, efficacy and outcomes.Design, setting and participants: A prospective study involving 185 public patients (221 eyes) referred to the Department of Ophthalmology at Flinders Medical Centre for cataract surgery. The study was conducted between February 2003 and August 2004.Interventions: Patients were assessed in the nurse-led preoperative assessment clinic. Those deemed suitable for cataract surgery were also assessed by an ophthalmologist and underwent cataract surgery if appropriate. The nurse managed postoperative care.Main outcome measures: Concordance between nurse practitioner and ophthalmologist assessments; waiting times for first clinic appointment and surgery; visual acuity and degree of visual disability; patient satisfaction.Results: 114 patients (61.6%) were assigned to see the ophthalmologist for cataract surgery. Median waiting times fell from 115 days (range, 23–268 days) to 21 days (range, 9–43 days) for initial clinic appointment, and from 44 days (range, 5–148 days) to 29 days (range, 14–154 days) for surgery. All 114 patients were listed for cataract surgery, and surgery had been performed on 121 eyes by the end of the study. After surgery, visual acuity improved by a mean of 0.45 logMAR (logarithm of the minimal angle of resolution) (SD, 0.24; range, 0.08–1.32). All patients had improved visual ability and high levels of satisfaction. Three quality assurance evaluations demonstrated full concordance between nurse and ophthalmologist assessments.Conclusions: Implementing a nurse-led cataract assessment clinic improved access to care for public patients with cataracts. The safety and efficacy of the program and its excellent visual and patient-centred outcomes commend its adaptation and implementation to other ophthalmology departments.

Bradley J Kirkwood MA · Konrad Pesudovs PhD · Paul Latimer FRCOphth · Douglas J Coster FRANZCO, AO

Objective: To report on strategies for, and outcomes of, evaluation of knowledge (publications), health and wealth (commercial) gains from medical research funded by the Australian Government through the National Health and Medical Research Council (NHMRC).Design and methods: End-of-grant reports submitted by researchers within 6 months of completion of NHMRC funded project grants which terminated in 2003 were used to capture self-reported publication number, health and wealth gains. Self-reported gains were also examined in retrospective surveys of grants completed in 1992 and 1997 and awards primarily supporting people (“people awards”) held between 1992 and 2002.Results: The response rate for the 1992 sample was too low for meaningful analysis. The mean number of publications per grant in the basic biomedical, clinical and health services research areas was very similar in 1997 and 2003. The publication output for population health was somewhat higher in the 2003 than in the 1997 analysis. For grants completed in 1997, 24% (31/131) affected clinical practice; 14% (18/131) public health practice; 9% (12/131) health policy; and 41% (54/131) had commercial potential with 20% (26/131) resulting in patents. Most respondents (89%) agreed that NHMRC people awards improved their career prospects. Interpretation is limited by the relatively low response rates (50% or less).Conclusions: A mechanism has been developed for ongoing assessment of NHMRC funded research. This process will improve accountability to the community and to government, and refine current funding mechanisms to most efficiently deliver health and economic returns for Australia.

for the National Health and Medical Research Council Evaluations and Outcomes Working Committee

Managing access block involves reducing hospital demand and optimising bed capacity Hospital overcrowding causing “access block” — a lack of available inpatient beds for emergency department patients — remains a major impediment to the delivery of good health care both in Australia and overseas. It is obvious that making elderly or disabled patients wait on uncomfortable emergency trolleys in corridors, with sleep deprivation and minimal privacy, is inhumane. Previous research has shown that hospital overcrowding is actually inefficient: it is associated with increased length of hospital stay,1,2 thus potentially reducing throughput. The number of adverse events has also been shown to increase with worsening access block.3,4 An overcrowded hospital should now be regarded as an unsafe hospital Two articles in this issue of the Journal have put pressure on efforts to solve this problem. Sprivulis and colleagues5 and Richardson,6 using different methods and different populations, have shown a strong association between access block and mortality rate. Their findings now make access block a patient safety issue for which all health care workers and the community must be responsible. It is incumbent on governments and administrators to prevent overcrowding by improving management of the health care system and, where necessary, providing increased resources. These two studies have certain methodological issues that require comment. Firstly, both studies used administrative databases. These are convenient and allow very large populations to be studied. Sprivulis et al, in their study, have also taken advantage of the linked databases in Western Australia and looked at outcomes beyond hospital admission, thus avoiding the potential bias of only studying outcomes in hospital. Unfortunately, many data elements are not available on administrative databases. Data on physiological variables, details of treatment and past medical history, for example, were not available to more accurately adjust for risk within patient groups. It is also likely that unknown confounders may have been present, such as changing referral patterns, patient choice, and non-seasonal changes to illness patterns. Despite this, the association between periods of overcrowding and increased mortality is quite strong. Both studies have attempted to adjust for obvious confounders such as age, type of illness, seasonal effect, and so on. What Sprivulis et al and Richardson have shown is that there is an association between overcrowding and mortality, not that overcrowding causes mortality. It is possible (but unlikely) that an influx of sick, elderly patients at high risk of death may actually cause overcrowding, thus resulting in the apparent association. Without a controlled intervention study, it is not possible to conclude that reducing overcrowding would reduce mortality. There are good reasons for assuming a causal relationship: known effects of overcrowding include delays in patient management, poor hospital processes, poor infection control, patients not being placed on the appropriate ward, and so forth. Given that it is logical that there is a causal relationship and that there is no known increased risk to patients under conditions of normal hospital bed occupancy, it is unacceptable to continue to allow hospital overcrowding to occur. There have been many attempts to ameliorate the problem of access block across Australia7 and internationally.8 The exacerbation of access block seen in the past few years is symptomatic of much larger changes occurring within the health system. Changes to workforce, working hours, aged care, and funding, as well as fewer hospital beds, and increasing demand for seemingly limitless new treatments and procedures, have all contributed to access block. Governments have responded to these challenges by increasing resources (health care now consumes 9.6 % of Australia’s gross domestic product9), improved monitoring of performance through various indicators, and myriad initiatives to improve efficiency within hospitals as well as divert some patients away from hospitals. This effort has alleviated access block in some jurisdictions,10 but there are still major difficulties across Australia. What should be done?There are two broad strategies for managing access block resulting from hospital overcrowding — reducing hospital demand and optimising hospital bed capacity. Reduce hospital demandDiversion/substitution: The major focus of this strategy has been to divert patients to community services and provide more services in the community that traditionally occur in hospital (eg, hospital outreach programs, hospital in the home, and improved after-hours general practice services). Reducing expectations: Reducing community expectations of what a public hospital system can provide is a politically sensitive strategy that has not been systematically addressed. Access block cannot be controlled without some limits being placed on the provision of services. Demand for health care is elastic and potentially unlimited, especially in an essentially free health care system. There must be public debate about what is essential versus what is desirable, and how much the community is willing to pay. Prevention: There is potential to reduce demand by disease prevention strategies, and improved management of patients with chronic ill health. Optimise hospital bed capacityImproved processes: There has been an enormous effort by health care workers to increase capacity by improved efficiency of health care delivery. Many initiatives with quick returns have already been implemented. Further significant improvements will need major investments in infrastructure, especially information technology. Workforce reform is necessary to increase the flexibility of the workforce and the capacity of the health care system. There is presently a shortage of virtually every type of skilled worker in the health care sector. Balancing elective and emergency workload: Contrary to popular opinion, the emergency workload is highly predictable across metropolitan areas. Elective treatment must be tailored to match the capacity allowed by predicted emergency work. Better discharge: Moving patients quickly from acute hospitals to more appropriate facilities increases hospital bed availability. Access to rehabilitation, residential aged care and community outreach programs is an essential component of an efficient and well managed health system. Addressing physical, social and psychological issues through care coordination in the emergency department and after hospital discharge can also help reduce hospital length of stay and readmission. Increased bed numbers: It is important to note that access block does not correlate well with the absolute number of hospital beds. Increasing the number of hospital beds temporarily alleviates access block, but does not solve the problem — the beds quickly fill and the problem recurs. Nevertheless, governments must fund an adequate number of beds to provide the health care that the community demands. An overcrowded hospital should now be regarded as an unsafe hospital. Health care workers should not have to provide services in an environment that potentially jeopardises patient safety. Government and communities must decide whether they want a well managed, adequately resourced health care system where demand is matched to available resources or to take their chances with the present system.

Peter A Cameron MB BS, FACEM, MD

Objective: To quantify any relationship between emergency department (ED) overcrowding and 10-day patient mortality.Design and setting: Retrospective stratified cohort analysis of three 48-week periods in a tertiary mixed ED in 2002–2004. Mean “occupancy” (a measure of overcrowding based on number of patients receiving treatment) was calculated for 8-hour shifts and for 12-week periods. The shifts of each type in the highest quartile of occupancy were classified as overcrowded.Participants: All presentations of patients (except those arriving by interstate ambulance) during “overcrowded” (OC) shifts and during an equivalent number of “not overcrowded” (NOC) shifts (same shift, weekday and period).Main outcome measure: In-hospital death of a patient recorded within 10 days of the most recent ED presentation.Results: There were 34 377 OC and 32 231 NOC presentations (736 shifts each); the presenting patients were well matched for age and sex. Mean occupancy was 21.6 on OC shifts and 16.4 on NOC shifts. There were 144 deaths in the OC cohort and 101 in the NOC cohort (0.42% and 0.31%, respectively; P = 0.025). The relative risk of death at 10 days was 1.34 (95% CI, 1.04–1.72). Subgroup analysis showed that, in the OC cohort, there were more presentations in more urgent triage categories, decreased treatment performance by standard measures, and a higher mortality rate by triage category.Conclusions: In this hospital, presentation during high ED occupancy was associated with increased in-hospital mortality at 10 days, after controlling for seasonal, shift, and day of the week effects. The magnitude of the effect is about 13 deaths per year. Further studies are warranted.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE

Russell Stitz,* Michael R Kidd,† Liz M Kenny,‡ Anne M Howard§ * President, Royal Australasian College of Surgeons, Spring Street, Melbourne, VIC 3000; † President, Royal Australian College of General Practitioners, Melbourne, VIC; ‡ President, Royal Australian and New Zealand College of Radiologists, Sydney, NSW; § President, Australasian College of Dermatologists, Sydney, NSW. college.presidentATsurgeons.org To the Editor: The MJA is to be congratulated on promoting the debate related to the significant increase in the number of “skin clinics”.1 Standards are important in both the maintenance of the facilities and the formal training of the practitioners undertaking the assessment and care of patients. The four medical Colleges actively involved in treating skin conditions, who have their training programs accredited by the Australian Medical Council and their selection and assessment processes authorised by the Australian Competition and Consumer Commission, are the Royal Australian College of General Practitioners (RACGP), the Royal Australian and New Zealand College of Radiologists (Faculty of Radiation Oncology), the Royal Australasian College of Surgeons (RACS), and the Australasian College of Dermatologists. The Colleges already have established standards for accreditation of facilities (eg, Guidelines and standards for day surgery in Australia <http://www.surgeons.org/Content/NavigationMenu/FellowshipandStandards/ AustraliaDaySurgeryCouncil/Guidelines_and_Stand.htm>, or the RACGP Standards for general practice <http://www.racgp.org.au/document.asp?id=17623>) and have well established programs for training medical practitioners in the treatment of skin conditions. The Colleges base these programs on high standard “holistic” care that is not influenced by entrepreneurial medicine. Our Colleges encourage the development of improved training programs at all times. It is important that we maximise the benefit of the structures and standards that currently exist. Our Colleges have already begun discussion about the ways we can build on our work to date. Our members, and the Australian public, expect specialist medical Colleges to take a lead in ensuring the quality of health care, and we will continue to do so.

Russell Stitz · Michael R Kidd · Liz M Kenny · Anne M Howard

Roslyn G Poulos,* Anthony B Zwi† * Lecturer, † Professor and Head, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052. r.poulosATunsw.edu.au To the Editor: We support the suggestion in the recent editorial on modernising the National Health and Medical Research Council (NHMRC)1 that the Council assess the outputs and value of sponsored research by going beyond considering primarily published articles and granted patents. More attention to mechanisms that improve the translation of research into policy and practice is required. As part of an NHMRC Capacity Building Grant in Population Health in Injury, Trauma and Rehabilitation, we have interviewed a number of Australian injury researchers to identify the facilitators of, and barriers to, enhancing the interface of research with policy and practice. Researchers readily reported peer-reviewed journals and conference presentations as measurable indicators of research success, but found policy and practice outcomes more difficult to identify. This may be because research utilisation often occurs through a slow and indirect process of “enlightenment”;2 however, it may also reflect minimal opportunities available, or taken, to disseminate research directly to policy makers and practitioners, and thereby encourage uptake. Some researchers perceived that funding bodies, such as the NHMRC, do not explicitly fund the person-time necessary for researchers to work with relevant stakeholders to disseminate their research. Without such funding, researchers must move onto the next funded project, without the opportunity to “value-add” to their research by facilitating uptake. Further, there may be little incentive from academia to develop relationships with policy makers, industry or practitioners.3 Such interactions should be considered as “part of the ‘real’ work of research”4 and should attract funding. The Canadian Health Services Research Foundation has identified the job of a knowledge broker as someone “to bring people — researchers, decision makers, practitioners and policy makers — together and build relationships among them that make knowledge transfer more effective” and has recommended that the task of brokering be acknowledged and rewarded.5 The Sax Institute in New South Wales is exploring a similar concept. In considering new approaches to assessing sponsored research, consideration should be given to ensuring the legitimate funding of research dissemination (however, and by whom, that is to be undertaken), and appropriate, objective measurements that reflect dissemination, with the potential to improve uptake. Those familiar with program evaluation will recognise the importance of measuring effective dissemination as a prerequisite to outcome evaluation, and as being highly relevant to the assessment of research output and influence.

Roslyn G Poulos · Anthony B Zwi

CorrectionRe: “Hospital in the home: what next?”, by Stephen F Wilson and Nicholas Collins, in the 6 February issue of the Journal (Med J Aust 2006; 184: 141-142). One author’s name was omitted from the byline. The letter’s authors are Stephen F Wilson, Program Director Population Health, Sacred Heart Rehabilitation Centre, St Vincent’s Hospital, Darlinghurst, NSW 2010; and Nicholas Collins, Ambulatory Care Specialist, Macarthur Health Service, Sydney, NSW. The html and pdf versions of this article were corrected on 7 February 2006.

Stephen F Wilson MB BS, FRACGP, FAFRM(RACP) · Nicholas Collins MB BS, FRACGP

In January 2001, a daily morning handover meeting (“morning report”), involving medical staff and students, began at the Launceston General Hospital, Tasmania. Periodic questionnaire surveys have been conducted to assess whether the morning report is fulfilling the quality improvement and educational needs of medical staff. The format of meetings has been successively modified in response to feedback. Participants have expressed a preference for patient-focused meetings, with less emphasis on formal teaching. A 12-month pilot study beginning in January 2004 has assessed the impact of adding a bed-management focus to the morning report. Over the period of the pilot study, there has been reduced bed access block, reduced average length of stay and increased bed availability. This suggests that a longer, more formal study may be warranted.

Robert G Fassett FRACP, FASN · Steven J Bollipo FRACP

Objective: To describe the workload profile in a network of Australian skin cancer clinics.Design and setting: Analysis of billing data for the first 6 months of 2005 in a primary-care skin cancer clinic network, consisting of seven clinics and staffed by 20 doctors, located in the Northern Territory, Queensland and New South Wales.Main outcome measures: Consultation to biopsy ratio (CBR); biopsy to treatment ratio (BTR); number of benign naevi excised per melanoma (number needed to treat [NNT]).Results: Of 69 780 billed activities, 34 622 (49.6%) were consultations, 19 358 (27.7%) biopsies, 8055 (11.5%) surgical excisions, 2804 (4.0%) additional surgical repairs, 1613 (2.3%) non-surgical treatments of cancers and 3328 (4.8%) treatments of premalignant or non-malignant lesions. A total of 6438 cancers were treated (116 melanomas by excision, 4709 non-melanoma skin cancers [NMSCs] by excision, and 1613 NMSCs non-surgically); 5251 (65.2%) surgical wounds were repaired by direct suture, 2651 (32.9%) by a flap (of which 44.8% were simple flaps), 42 (0.5%) by wedge excision and 111 (1.4%) by grafts. The CBR was 1.79, the BTR was 3.1 and the NNT was 28.6.Conclusions: In this network of Australian skin cancer clinics, one in three biopsies identified a skin cancer (BTR, 3.1), and about 29 benign lesions were excised per melanoma (NNT, 28.6). The estimated NNT was similar to that reported previously in general practice. More data are needed on health outcomes, including effectiveness of treatment and surgical repair.

David Wilkinson MB ChB, DSc, FRACGP · Deborah A Askew BAppSci, MHlthSci, PhD · Anthony Dixon MB BS, FACRRM

Paul D Fitzgerald General Practitioner, Suite 303, 83 Mount Street, North Sydney, NSW 2060. docfitzATihug.com.au To the Editor: It is heartening to see a positive professional response to clinical quality systems in the wake of Bundaberg. However, these are secondary responses, and overlook the primary, preventive solution. Clinical monitoring systems presuppose that some damage is done before a problem becomes apparent. Hospitals already have mechanisms to examine clinical competence, and their appointments credentialing and privileging procedures. The Queensland Health Systems Review Final Report (the Forster report)1 comments repeatedly on the apparent failure of these procedures in the Patel case at Bundaberg Hospital: It appears that the process of checking credentials did not involve the College of Surgeons and no written clinical privileges appeared to have been granted on appointment. (p 169) The report draws specific attention to special purpose registration for areas of need, pointing out the inherent conflict of interest: As an employer under pressure to fill medical vacancies, Queensland Health faces a conflict of interesting making . . . determinations of area of need to allow special purpose registration of overseas trained doctors. (p 175) It adds that these doctors are not subject to the same requirements as locally trained doctors, and recommends: No overseas trained doctor should commence employment in a senior position intended to be filled by a specialist before . . . [assessment via the established Australian Medical Council / Specialist College pathway]. (p 174) Furthermore, deemed specialists should participate in the usual clinical performance management processes applicable to all doctors. (p 175) And, finally: . . . local clinical leaders and managers have a conflict between credentialing someone about whom they are uncertain and having no one to deliver the service. It appears that these issues may have been relevant at Bundaberg. (p 176) More recently, the Queensland Public Hospitals Commission of Inquiry report (the Davies report)2 confirms a practice of appointing overseas trained doctors as senior medical officers in specialist roles in hospitals in designated areas of need. Such appointments in Bundaberg, Hervey Bay, Townsville and Charters Towers not only bypassed procedures for recognition as a “deemed specialist”, but were also not considered by hospital credentialing and privileging committees. The Davies report states that, in some hospitals, these committees did not exist. It may be premature for the proponents of clinical quality systems to dance on the ashes of Bundaberg. These recent reports outline a chain of existing systems problems including the Medical Board, the Department of Health, successive Health Ministers and Cabinets, and appointments, credentialing, privileging and complaints procedures in a sample of Queensland public hospitals. According to the Davies report (section 6.173), around half of the doctors in Queensland public hospitals were appointed under area-of-need arrangements by 2002. How are other states balancing the politically sensitive area of need registration with long-standing appointments, credentialing and privileging procedures?

Paul D Fitzgerald

We need to create a range of new health practitioners who can deliver patient-friendly care On 22 and 23 November 2005, some 200 health professionals, including doctors, nurses and other health professionals, met in Brisbane to discuss education and training issues for the future health workforce. The meeting, sponsored by the University of Queensland and Queensland Health, accepted that providing health care for an ageing population afflicted with chronic disease requires a health workforce that is more flexible, mobile and multiskilled than our current one, and this will require creative thinking about future workforce requirements. Key issues addressed at the meeting included: What will be the health care requirements in 2010–2020? Who is going to deliver these services, and how? How are these health care practitioners to be trained? What are the issues of accreditation of these practitioners? How are we going to pay for these services? William Doe (Dean of the Faculty of Medicine, University of Birmingham) discussed some of the changes that are occurring in the United Kingdom’s National Health Service (NHS). These relate to the National Practitioner Program, which tackles traditional and longstanding barriers to change, such as professional boundaries, team structure, hierarchies and existing care processes. The program involves expanding the depth and breadth of roles and creating new job descriptions so that different health professionals at similar levels of responsibility can share a number of care competencies in addition to those unique to their own role. An important enabler in the NHS has been the establishment of a generic competency-based skills escalator, involving all non-medical health professions. This framework has eight steps, beginning with a Junior Assistant and ascending to a consultant Health Professional Practitioner. Foundation degrees allow a broader range of people access to health careers, commencing in the newer roles lower on the skills escalator. New roles described by Doe include the Medical Care Practitioner, which is based on the physician assistant model in the United States and will have a skill and knowledge base to deliver most generalist diagnoses, treatment and care within general medical and family practice. Science graduates, NHS staff and armed health services staff are the expected source of recruits, and there are plans for a 2-year university degree course, developed with input from universities and royal colleges. This course will lead to a statutory registered qualification and registration, probably on the health professions register. Although there will be considerable autonomy for Medical Care Practitioners, they will work under the supervision of a qualified medical practitioner. Surgical Care Practitioners will tend to be drawn from nurses and other health care practitioners, and will assist in delivering surgical services to patients under the supervision of a consultant surgeon. Again, this role is being developed in collaboration with the Royal Colleges of Surgeons and Nursing. Anaesthesia Practitioners will perform pre- and postoperative assessment care, maintain anaesthesia and, under direct supervision of a specialist anaesthetist, conduct the induction of and emergence from anaesthesia. Debra Humphris (Director of the Health Care Innovation Unit at the University of Southampton) described significant changes that are occurring in southern England in relation to the delivery of primary care. She noted that patients’ needs may be much simpler than what we wish to provide. The new models of care increasingly reflect the importance of effective teamwork, collaboration and real role change, coupled with improvements in productivity, but can only be developed through a close relationship between the academic institutions, local policymakers, service providers and patients. Jane Barnacle (Health Care Innovation Unit, University of Southampton) described the development of a new role: Community-Based Rehabilitation Assistant. This role is level 4 on the NHS skills escalator (Assistant Practitioner). The role was designed after a task analysis of the delivery of post-hospital care at home showed that 80% of the care delivered was not discipline-specific, was poorly coordinated (in one case by 17 different providers) and of poor productivity, with much time spent in driving. The training required is a foundation degree, developed in close association with local employers, which includes a generic first year and more specific second year, and emphasises structured competency-based training in the field. Bonnie Sibbald (Chair of Health Services (Research), University of Manchester) presented data on nurse practitioner experience in the United Kingdom. Nurses are increasingly working alongside doctors in primary care, assisting doctors in tasks ranging from blood sampling or syringing ears to more advanced roles in health care promotion and management of patients with stable chronic conditions such as asthma, diabetes, cardiovascular disease and arthritis. Sibbald also presented the details of a Cochrane review of nurse practitioners.1 The review showed the same or better outcomes for patients in services delivered by nurse practitioners or by general practitioners, and showed that nurse practitioners are well accepted by patients. Issues that need to be carefully addressed in using nurse practitioners include continuity and coordination of care, which may be an issue particularly if the team becomes too big (greater than 10). There may be significant initial capital costs in terms of producing nurse practitioners and, of course, the nursing profession is as much in short supply as the medical profession. Rod Hooker (Associate Professor, Department of Physician Assistant Studies, University of Texas, Southwestern Medical Center Dallas, Tex) presented the US experience with physician assistants. There are now some 65 000 physician assistants in the US, graduating from some 130 programs, mostly attached to Faculties of Medicine or Health Sciences. The physician assistants cover a vast range of tasks from anaesthesia, acute care, public health, surgery, pathology, radiology, chronic disease management and primary care. He presented data that suggest that physician assistants take up about 10% of the time of the supervising doctor but can address 85% of the caseload of the physician in most situations. The educational programs run for around 24 months and the cost of educating a physician assistant is about 20% of that of a medical practitioner. It was felt that physician assistants could address a number of the problems currently facing the Australian health care system, particularly in primary care, chronic disease, some procedures (colonoscopies, etc), and in rural and remote Australia. Amanda Adrian (Health Care Consultant, NSW) discussed the issues of nurse practitioner legislation in Australia and pointed out some of the complexities of the legislative process for health practitioners (the Productivity Commission recently noted that there are more than 90 registration bodies for health practitioners in Australia2) and the difficulties for health practitioners in moving between jurisdictions. She highlighted that much legislation can be disabling (rather than enabling), and this may be why so few nurse practitioners are actually working in Australia. Tony Austin (Head, Defence Health) presented the final formal presentation. He noted that the military has a long tradition of innovation in health care delivery and gave particular emphasis to the important roles of medics (medical assistants). One feature of the military medic group is their variation — to meet the differing needs of the three Services (Army, Navy and Airforce). A major concern at the moment is the lack of articulation for medics with the civilian community. Although there is some scope for this with paramedics and nursing, there are also significant limitations. The development of a physician assistant program in civilian life would provide a valuable opportunity for army medics on discharge from the Defence forces. Peter Brooks then gave a brief overview of the Productivity Commission’s draft report,2 emphasising its recommendation for the establishment of an Advisory Health Workforce Improvement Agency to facilitate workplace innovation, and the possibility of shifting the primary responsibility of funding from the education sector to the health sector to allow more responsive education and training arrangements. The report discussed the need for a consolidated national accreditation regime and the establishment of uniform national registration standards and improved mutual recognition. The report also recommended the establishment of an independent review body to advise on services to be covered by the Medicare Benefits Schedule and on referral and prescribing rules. In addition, the report recognised the importance of an adequate database on workforce and of creating better solutions to the problems of rural and remote areas and groups with special needs. Discussion took place in relation to the importance of addressing remuneration for health services and particularly a revisitation of the Relative Value Study with a redistribution of funding away from procedures and towards the “considered opinion”. Wide-ranging discussion on Day 2 of the conference covered areas supporting the development of integrated care models, the importance of getting general practitioners more involved in preventive care, and a focus on health professionals and creating meaningful work environments for these individuals. The meeting reflected a groundswell of feeling within the Australian health system that change must happen and that we, as key players in that system, must help to drive that change. We need to create a health system (not an ill system, as we currently have), continue to develop partnerships to break down the professional silos, and create a range of new health practitioners who can deliver care in a patient-friendly fashion. Many participants considered that a key to workforce innovation is a back-to-basics review of what consumers want and what services should be provided. It was proposed that a key question is the level of skill required of the person providing the initial assessment in primary care. Is it someone who should be able to handle 100% of conditions presenting? Or is someone who can handle 70% and refer the other 30% acceptable? There was general support for the concept of a wide range of delegated care, especially physician assistants and nurse practitioners. The associated changes to the Medical Acts which this would require were felt to be an important area of reform that needs to be urgently addressed. Delegated payment systems, where payment could be made to a practice rather than an individual, were preferred. Many speakers supported streamlining of the regulatory processes and the development of a competency-based modular education system. There was support for a better aligning of the health and education sectors, particularly in regards to policy. Although there was support for the Productivity Commission’s draft document, some participants that felt that it would be difficult to implement many of the suggested changes. There was strong support for local action to introduce appropriate innovations, and a sense that this could and should be done, with or without central reform. Participants were keen to continue the health workforce innovation agenda in the future.

Peter M Brooks FRACP, FAFRM, FAFPHM · Niki Ellis MB BS, FAFOM

Katina Kardamanidis,* Bruce Armstrong† * Research Fellow, Injury Prevention and Trauma Care, The George Institute for International Health, PO Box M201, Camperdown, NSW 2050; † Head, School of Public Health, University of Sydney, NSW. kkardATdoh.health.nsw.gov.au To the Editor: Not all asylum seekers in Australia are confined to detention centres. Those who arrive with a valid visa live in the community. If they apply for refugee status within 45 days of arrival, they are entitled to work and to Medicare while their refugee claims are processed;1 if they apply too late, they are denied these benefits. In New South Wales in 2003 about 1500 men, women and children were in this situation, which may last from 3 months to 3 years. Asylum seekers who appeal a refusal of their application, or are released from mandatory detention with an application outstanding, are in the same situation.2 Some are eligible for the federally funded Red Cross Asylum Seeker Assistance Scheme, but, for most, access to health care is jeopardised because they are unable to pay full fees for medical services.3,4 We asked health professionals working with asylum seekers about the costs of asylum seekers’ difficulties in accessing health care. Their responses, with illustrative quotes, are divided into “tangible costs” and “intangible costs” (Box). Some individuals and institutions sympathetic to the plight of asylum seekers give their professional time or donate money to pay for health care, but are not able to address the full range of health care needs. Obtaining access to secondary care, particularly admission to hospital, is very difficult. There is no uniform approach to charges, either between hospitals or within any one hospital on different occasions. The approach seems to depend on the decision-maker present. Such difficulties in accessing care may lead to uncomplicated health problems developing into chronic and more serious ones. The attempt to save costs is likely to lead to higher costs in the future. The effect on asylum seekers is increased physical, psychological and social disadvantage and diminished opportunities for a healthy life. Health professionals are faced with the dilemma of turning these people away, or aiding them without financial compensation. In either case, they cannot provide the necessary standard of care. Although many Australians are conscious of the hardship of these people, the society as a whole seems unaware of it or of the impact that its unfairness may have on the social fabric of their communities. If all Medicare-ineligible asylum seekers in NSW were to have the same access to health services as other Australians, we estimate that the total annual cost would be about $3.4 million.5 This is about 0.015% of the total annual recurrent health expenditure in NSW in 2000–01.6 This economic cost, some if not most of which will be spent regardless, does not justify the disadvantage created by the Australian Government’s immigration rules. We suggest that state governments consider giving this small group of asylum seekers free access to public hospital services. Costs of asylum seekers’ difficulties accessing health care and who bears the costs: responses of health professionals working with asylum seekers Theme Illustrative quote Tangible costs Insufficient voluntary aid to address all health needs “We have one patient . . . with a urinary infection, and it was decided that . . . he needed a TURP [transurethral resection of the prostate], and then they realised he didn’t have any funds and they discharged him . . .” Inconsistent attitudes of hospitals “There’s quite a difference between different hospitals. For example, the X hospital at Y is very tough. . . . much tougher than the hospital here, on refugees. . . . They are different Area Health Services . . . it may not even be the Area Health Service directors, but the hospital manager’s idea that these people should pay.” More costs in the long term “I have a lot of patients with diabetes and high blood pressure . . . Now if their diabetes or their blood pressure or their cholesterol is not managed properly, then they get heart disease or strokes. So, I have a patient who has had a stroke . . . high blood pressure and so on . . . if he had [had] better access to health care, would he have had the stroke? . . . So [now], the government has had to pay . . . it doesn’t make any sense really.” Intangible costs To the asylum seeker (recounted by a health professional) “If you say to someone, I really think you need to have this test, but, if I refer you, you have to pay a lot of money, so I’m not going to refer you, how does that make you feel? It makes you feel worried and powerless.” To health professionals “. . . if someone came in complaining about it [diarrhoea, losing weight], you would do a whole lot of checks, and with that particular lady . . . we were able to negotiate to get a couple of tests done free, and the family and she paid a certain amount of money to get some others [done] . . . if the person had Medicare, you’d take it that step further and do extra just to be 101% sure. So, there is that real ethical dilemma . . .” To the Australian society “. . . if people actually knew on a face-to-face level . . . what it meant to deny a newborn baby the right to health care, [or] . . . turn away someone who is extremely depressed . . . [Would they] actually be able to say ‘No, they don’t [have a right to health care]’.”

Katina Kardamanidis · Bruce Armstrong

To the Editor: British authors Wilson and Parker in their editorial on hospital in the home1 acknowledge the outdated Cochrane review of 20012 in relation to costs of hospital in the home. More recent research in New South Wales provides compelling evidence of cost saving in excess of 50% when community costs are compared with inpatient costs for certain diagnosis related groups.3,4 Patient selection for these services is based on safety, functional ability, carer support, and consent. The treatment regimens are based on evidence and governed by strict quality assurance. These elements form the foundations of successful acute and post-acute care programs. Amendments to the National Health Act 1953 (Cwlth) in 2001 endorsed the provision of acute care in places other than hospital beds.5 The Macarthur Health Service in south-western Sydney received Commonwealth acute outreach accreditation in 2004 and currently supplies at least 13% of total bed-days in the specialties of medicine, surgery and paediatrics. An added benefit is a system that allows people to choose a private outreach service instead of a hospital bed and have expenses covered by their health fund, which pays a bed-day rate for this care in the community. Patient quality of care, choice and satisfaction have been the drivers for hospital in the home. Demonstrated savings for ambulatory sensitive diagnoses and the opportunity for revenue from private patients should be appealing to hospital administrators in an environment of chronic bed shortages. Editor’s note: The Cochrane review was updated after Wilson and Parker submitted their editorial: Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care. Cochrane Database Syst Rev 2005; (3): CD000356. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000356/frame.html (accessed Dec 2005).

Stephen F Wilson · Nicholas Collins

Stephen F Wilson,* Peter McGeorge† * Program Director, Population Health, Sacred Heart Rehabilitation Centre, † Director of Mental Health Service, St Vincent's Hospital, Darlinghurst, NSW 2010. stwilsonATstvincents.com.au To the Editor: Corbett’s recent proposal to create a “Ministry for the Public’s Health” has merit. However, this Ministry may not achieve its intended purpose in relation to disadvantaged people, chronic and complex health care, or the mental health problems confronting acute services in today’s urban communities. The current situation may be the result of long neglect of population health. However, a new Ministry runs the risk of becoming yet another compartment within an existing non-integrated health care system. The efficiencies of an integrated service for acute health care of older people are well known.2 This integration requires a reinvestment in community care and changes in roles and relationships of health workers. There is currently a gap between services maintained by state funding for acute care in and around hospitals, and services which are federally funded for the community sector via general practice, preventive and maintenance services. The gap created between these two workforces results in suboptimal “management” of chronic and complex disease and mental health, and care of disadvantaged groups. The lack of a strong focus on management drives patients to rely on the acute health care system, particularly emergency departments. This situation is aggravated by the poor coordination with general practice, non-government organisations and community services. The current challenge is to develop a health environment which simultaneously addresses the present and future needs for prevention, management and response. Another approach is to construct a health “sandwich”, with a foundation layer of population health, a “filling” of illness management services, and a top layer of acute response and hospital services. A model guided by the mission of St Vincent’s Hospital, and implemented in 2005, has created a partnership for emergency department, community health, aged care, rehabilitation and palliative care within an administrative division called Population Health. A Psychiatric Emergency Care Centre within the emergency department has established a shared approach to acute patient care along with the mental health services. In the future, a patient entering the emergency department for an acute response to physical, mental or combined illness should also be “consuming” a health program of management and disease prevention, which is lacking in current health service provision. This healthy sandwich may prove easier to digest than the dry biscuits of policy.

Stephen F Wilson · Peter McGeorge

Men seek help and use health services less frequently than women do. Men’s help-seeking practices and health service use are complex issues involving biological, psychological and sociological considerations. Most discussion on men’s help-seeking positions them as reluctant consumers or “behaving badly” with respect to their health. Few studies have explored whether health service providers are equipped to deal with men’s health issues appropriately. The current health system appears not to be tailored to meet the health needs of men. Better collaboration is required across disciplines, to further investigate men’s health using both qualitative and quantitative research methods.

James A Smith · Annette Braunack-Mayer PhD · Gary Wittert MB BS, FRACP

CorrectionRe: “The use of cusum analysis in the early detection and management of hospital bed occupancy crises”, the research article by Claire M Burns, Cameron J Bennett, Colin T Myers and Michael Ward, in the 19 September issue of the Journal (Med J Aust 2005; 183: 291-294). The first row of data in Box 1 should have read No. of samples (referring to the number of days in each 6-month study period, with one set of measurements being made each day), rather than No. of patients. The html and pdf versions were correct when published.

Claire M Burns RN, BNursing · Cameron J Bennett MB BS, FRACP · Colin T Myers MB ChB, FACEM · Michael Ward MB BS, FRACP

Contributing to health services research, implementation and effective health policy-making Some of the most pressing issues in Australian health care are not about the efficacy of particular treatments, but rather how health services can be organised to deliver optimal care. Examples of service-related initiatives familiar to most clinicians include: multidisciplinary teams to improve coordination of cancer care; designated trauma centres to optimise management of injured patients; financial incentives to encourage particular services; restricted licences for overseas medical graduates to increase the rural workforce; specialist outreach and telemedicine to improve access in remote areas; clinical audit and review to enhance care quality; and management and prescribing guidelines. Broadly speaking, these represent a spectrum of organisational, financial, regulatory and professional interventions aimed at improving service delivery and achieving best practice. Just as clinicians and patients are concerned with the effectiveness of clinical treatments, policy-makers and the public are interested in the effectiveness of health system interventions. For clinical treatments, questions about “what works” may be best answered using randomised controlled trials and other experimental designs. Those studying the effectiveness of health service interventions, however, face some specific methodological and analytical challenges, and often need to consider other types of designs. Is it possible to randomise communities to receive outreach visits, for example? What are the important outcomes of employing nurse practitioners in remote areas? Can we effectively control for other health service changes, such as closure of a hospital, or loss of staff, that may be unavoidable during a study period? In studies in which the intervention is delivered to a population, but the outcomes are measured in individual patients, how do we take clustering effects into account in the analysis? Australians have contributed to developing appropriate methods (some adapted from economics and social sciences) for addressing such questions in real-world situations. Support for the Australian health services research community has come from the Health Services Research Association of Australia and New Zealand (http://www.chere.uts.edu.au/hsraanz/), established in 2001, the longstanding interest of The Medical Journal of Australia, as well as other organisations, and the Australian and New Zealand Journal of Public Health, Australian Health Review, and a new open-access journal, Australia and New Zealand Health Policy (http://www.anzhealthpolicy.com). Syntheses of available research also contribute to rational health policy-making. The international Cochrane Collaboration maintains systematic reviews in which the research literature on a topic has been identified, selected, appraised and synthesised in a transparent way.1 Such reviews reduce the likelihood of people being misled by research findings, and increase the confidence in what outcomes can be expected from an intervention.2,3 However, reviews of health service interventions differ in that, to be useful for policy-makers and managers, the goal of methodological rigour that characterises Cochrane reviews needs to go hand in hand with an understanding of the challenges inherent in health services research. The Cochrane Collaboration’s Effective Practice and Organisation of Care (EPOC) Group, based in Ottawa, Canada, is dedicated to conducting reviews of interventions designed to improve professional practice and the delivery of effective health services, potentially spanning any clinical area.4 It has already produced 37 reviews on topics such as audit and feedback, discharge planning, hospital in the home, printed educational materials, telemedicine and specialist outreach. A particular focus of EPOC has also been how to broaden the types of included studies beyond blinded randomised trials, while at the same time optimising validity and generalisability. These include designs such as controlled before–after studies and interrupted time series studies. Recognising that evidence for policy-making is not always readily available, the Australian Government has provided for a new partnership between EPOC and the National Institute of Clinical Studies (NICS). The Australian EPOC satellite at the National Institute of Clinical Studies was officially announced at the Cochrane Colloquium in Melbourne on 22 October 2005. NICS is funded by the Australian Government to help improve uptake of evidence into clinical practice, and to use evidence about individual, organisational and system change in designing implementation programs. In addition, free access to the Cochrane Library (and a user’s guide) is available through the NICS website (http://www.nicsl.com.au). The overall goal of the satellite is to assist evidence-based policy-making through systematic reviews of interventions designed to improve health care practice and the delivery of effective health services relevant to Australia and our region. In particular, the satellite aims to: identify and help produce priority EPOC reviews relevant to Australia; support EPOC review activity through training and mentoring of researchers; and foster a culture of evidence-based health policy and knowledge translation by promoting the use of the Cochrane Library, and EPOC reviews in particular. In addition, the Australian satellite will: support the EPOC editorial base in Canada by editing, producing and updating EPOC reviews, especially reviews relevant to rural areas; collaborate with the Australasian Cochrane Centre and the other Australian-based Cochrane groups to further the work of the Cochrane Collaboration in the region; and contribute to the international effort of synthesising research to improve evidence uptake. We hope that the satellite will make an ongoing contribution to Australian health services research, implementation and effective health policy-making.

Russell L Gruen MB BS, PhD, FRACS · Heather Buchan MB ChB, MSc, FAFPHM · Jan Davies PhD, MBA · Alain Mayhew MSc · Jeremy M Grimshaw MB ChB, PhD, FRCGP

Objectives: To examine the commercial development of Australian medical patents and identify the determinants of their being used in innovations (new or improved products or production processes).Design: Cross-sectional survey with a nested case–control study.Participants and setting: 177 inventors listed as the first Australian on medical patents granted in the United States between 1 January 1984 and 30 December 1994, and surveyed in 1998–1999.Main outcome measure: A series of predictor variables (including characteristics of the patents; characteristics of the inventors; ideas, advice and funding during commercialisation; and the process of commercialisation) for whether or not a patent became an innovation.Results: Half (89/177) of the medical patents became innovations, with 34% generating a total of A $287 million (13% over $1 million) in annual sales a median of 8 years after the patent had been granted. A patent was more likely to become an innovation if the inventor was employed by industry at the time of invention (odds ratio [OR], 3.2; 95% CI, 1.1–9.2), had invested their own finances (OR, 2.8; 95% CI, 1.0–7.4), and if the patent had been licensed (OR, 4.6; 95% CI 1.7–12.7), led to further patents (OR, 3.2; 95% CI, 1.0–10.4) and involved an industry partner in its commercial development (OR, 10.1; 95% CI, 3.6–27.7). It was less likely to become an innovation if finance came from a research funding agency (OR, 0.3; 95% CI, 0.1–0.8) and if interest from Australian industry was judged by inventors as “poor” (OR, 0.6; 95% CI, 0.4–0.9).Conclusions: Medical patents in the US listing Australian inventors are more likely to become innovations if they originate from industry rather than the public sector, and if inventors are willing to invest their own finances.

Eugen Mattes MPH, PhD, FRACGP · Michael C Stacey DS, FRACS · Dora Marinova BEng, MSc, PhD