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Biliary hamartomas were an incidental finding in a 33-year-old man who was investigated for recurrent episodes of biliary colic. A T2-weighted coronal image showed multiple small hyperintense lesions of similar size scattered in both lobes of the liver (Figure). Biliary microhamartomas (von Meyenburg complexes) are rare and usually multiple. They occur because of ductal plate malformation and are composed of dilated intralobular and interlobular bile ducts.1 They generally remain asymptomatic and do not affect liver functions, and are most commonly detected incidentally.2 Differential diagnosis of this rare clinical entity includes multiple simple liver cysts, Caroli disease and, less commonly, metastatic liver disease (with necrosis).
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Learning from a tragedy to increase public awareness and improve responses in future thunderstorm asthma events
Thunderstorm asthma is the occurrence of acute asthma either during or immediately after a thunderstorm and it is often characterised by a surge in emergency asthma presentations. The epidemic of thunderstorm asthma in Melbourne, Australia, on 21 November 2016 was the most extreme such event ever worldwide, with nine fatalities currently the subject of a coronial inquiry.1,2 Hospitals and ambulance services were placed under record pressure, and supplies of reliever medications were exhausted at some health services.1 Key tasks for the future are to predict the thunderstorms most likely to lead to asthma outbreaks and to define how best to respond. Further research to better anticipate these outbreaks is crucial and planning for the inevitable recurrence must occur at patient, institutional and state-wide levels.
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We thank Edwin Lampugnani (University of Melbourne) for kindly supplying the image in . Jeremy Silver's work was funded by the MacKenzie Postdoctoral Fellowship scheme at the University of Melbourne.
In the past 5 years, Jo Douglass has received honoraria for educational presentations from AstraZeneca, GlaxoSmithKline, Stallergenes Greer, Novartis, Alphapharm, Shire, Mundipharma and Seqirus; has sat on advisory boards for Novartis, GlaxoSmithKline, Astra-Zeneca, Pieris, Stallergenes Greer and Seqirus; and has undertaken contracted and investigator-initiated research for GlaxoSmithKline, Novartis, AstraZeneca and Sanofi-Aventis. Jeremy Silver and Ed Newbigin are investigators on the National Medical and Health Research Council PBH grant 1116107, which partners with Stallergenes Greer. Christine McDonald has received honoraria for education presentations or advisory board participation from GlaxoSmithKline, Novartis and Pfizer.
There is much debate about public disclosure of individual doctors’ performance to increase hospital quality and safety, but research is lacking
In 2016, media coverage of a cluster of preventable deaths of babies born at a Victorian health service1 shone a spotlight in Australia on the role of public reporting of hospital performance data in assuring quality and safety. The subsequent Victorian government review2 suggested that the Victorian health system must develop a culture of candour with improved transparency at every level of the hospital system “through greater public reporting of outcomes data and support for a just culture in hospitals”.2 Other failures in hospital quality have similarly triggered inquiries and health system reform in Australia.3,4 For example, Queensland’s Bundaberg Hospital scandal in 2005 triggered changes to public reporting to further encourage cultures in hospitals to move away from the “name–shame–blame” approach.5
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Objective: To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury.
Design, setting and participants: A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007–2015.
Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type.
Results: There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00; 95% CI, 0.99–1.01; P = 0.70), motorcyclists (IRR, 0.99; 95% CI, 0.97–1.01; P = 0.45) or pedestrians (IRR, 1.00; 95% CI, 0.97–1.02; P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08; 95% CI; 1.05–1.10; P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007–2015, although the cost per patient declined for all road user groups.
Conclusions: As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.
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The Victorian State Trauma Registry (VSTR) is funded by the Department of Health and Human Services, the State Government of Victoria, and the Transport Accident Commission. Ben Beck received salary support from the National Health and Medical Research Council (NHRMC) Australian Resuscitation Outcomes Consortium (Aus-ROC) Centre of Research Excellence (1029983). Peter Cameron was supported by an NHMRC Practitioner Fellowship (545926) and Belinda Gabbe by an NHMRC Career Development Fellowship (GNT1048731). Warwick Teague’s role as director of trauma services at the Royal Children’s Hospital, Melbourne, is supported by a grant from the Royal Children’s Hospital Foundation. We thank the Victorian State Trauma Outcome Registry and Monitoring (VSTORM) group for providing VSTR data. We also thank Sue McLellan for her assistance with the data, Pam Simpson for her statistical support, and David Attwood from the Transport Accident Commission for his suggestions and advice.
No relevant disclosures.
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I thank Ellen Tailby for research assistance, Philippa Sutton for editing and managing earlier versions of the manuscript, and Sergio Duque and Lesley Baker for the volumetric modulated arc therapy plan of the patient shown in Box 5.
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Nicholas Talley is Editor-in-Chief of the Medical Journal of Australia.
Objectives: To determine the proportion of Aboriginal Controlled Community Health Service (ACCHS) patients tested according to three national diabetes testing guidelines; to investigate whether specific patient characteristics were associated with being tested.
Design, setting and participants: Cross-sectional study of 20 978 adult Indigenous Australians not diagnosed with diabetes attending 18 ACCHSs across Australia. De-identified electronic whole service data for July 2010 – June 2013 were analysed.
Main outcomes measures: Proportions of patients appropriately screened for diabetes according to three national guidelines for Indigenous Australians: National Health and Medical Research Council (at least once every 3 years for those aged 35 years or more); Royal Australian College of General Practitioners and Diabetes Australia (at least once every 3 years for those aged 18 years or more); National Aboriginal Community Controlled Health Organisation (annual testing of those aged 18 years or more at high risk of diabetes).
Results: 74% (95% CI, 74–75%) of Indigenous adults and 77% (95% CI, 76–78%) of 10 760 patients aged 35 or more had been tested for diabetes at least once in the past 3 years. The proportions of patients tested varied between services (range: all adults, 16–90%; people aged 35 years or more, 23–92%). 18% (95% CI, 18–19%) of patients aged 18 or more were tested for diabetes annually (range, 0.1–43%). Patients were less likely to be tested if they were under 50 years of age, were transient rather than current patients of the ACCHS, or attended the service less frequently.
Conclusions: Some services achieved high rates of 3-yearly testing of Indigenous Australians for diabetes, but recommended rates of annual testing were rarely attained. ACCHSs may need assistance to achieve desirable levels of testing.
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The authors gratefully acknowledge the generous support of the staff and patients from the following Aboriginal Community Controlled Health Services (in alphabetical order): Anyinginyi Health Aboriginal Corporation, Bega Garnbirringu Aboriginal Health Service, Danila Dilba Biluru Butji Binnilutum Health Service, Derbarl Yerrigan Health Service, Dhauwurd-Wurrung Elderly and Community Health Service, Kirrae Aboriginal Health Service, Mawarnkarra Health Service, Mildura Aboriginal Corporation, Mitwatj Health Aboriginal Corporation, Pika Wiya Health Service, Riverina Medical and Dental Aboriginal Corporation, South West Aboriginal Medical Service, Sunrise Health Service Aboriginal Corporation, Umoona Tjutagku Health Service, Winnunga Nimmityajah Aboriginal Health Service, Ampilatwatja Health Centre Aboriginal Corporation, Pius X Aboriginal Corporation, and Victorian Aboriginal Health Service.
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Objective: To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain.
Design: Quasi-experimental design, with interrupted time series analysis for the period October 2013 – November 2015.
Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland.
Intervention: Implementation of the ADP by structured clinical re-design.
Main outcome measures: Primary outcome: hospital LOS. Secondary outcomes: ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS).
Results: Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74–0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72–0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3–78.5%) to 54.9% (95% CI, 44.7–67.6%; P < 0.01). The estimated release in financial capacity amounted to $2.3 million as the result of reduced ED LOS and $11.2 million through fewer hospital admissions.
Conclusions: Implementing an evidence-based ADP for assessing patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.
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The ACRE Project was funded by the Queensland Government Department of Health. We acknowledge the support of the Healthcare Improvement Unit, Queensland Department of Health. We thank the Queensland Research Linkage Group of the Department of Health for assistance with linking data from the emergency department and inpatient datasets. We also gratefully acknowledge the contributions of former project officers Jennifer Bilesky, Jo Sippel and Vandana Bettens in the early development of the project, and the staff of the participating hospitals.
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In published research, a statistically significant result is often wrongly interpreted as representing a clinically important finding. In this article, we explore the meanings of statistical and clinical significance.
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Abstract
Objective: To compare the effectiveness of rehabilitation after total knee arthroplasty (TKA) in models with or without an inpatient rehabilitation component.
Design, setting and participants: A propensity score-matched cohort of privately insured patients with osteoarthritis who underwent primary, unilateral TKA in one of 12 Australian hospitals between August 2013 and January 2015 were included. Those discharged to an inpatient facility because of poor progress or who experienced significant complications within 90 days of surgery were excluded.
Intervention: Discharge after surgery to an inpatient rehabilitation facility or home.
Main outcome measures: Patient-reported knee pain and function (Oxford Knee Score; at 90 and 365 days after surgery) and health rating (EuroQol “today” health scale; at 35, 90 and 365 days). Inpatient and community-based rehabilitation provider charges were also assessed.
Results: 258 patients (129 pairs) from a sample of 332 were matched according to their propensity scores for receiving inpatient rehabilitation; covariates used in the matching included age, sex, body mass index, and markers of health and impairment. The only significant difference in outcomes was that EuroQol health scores were better on Day 35 for patients not undergoing inpatient rehabilitation (median difference, 5; IQR, –10 to 19; P = 0.01). Median rehabilitation provider charges were significantly higher for those discharged to inpatient therapy (total costs: median difference, $9500; IQR, $7000–11 497; P < 0.001; community therapy costs: median difference, $749; IQR, $0–1980; P < 0.001).
Conclusions: Rehabilitation pathways incorporating inpatient rehabilitation did not achieve better joint-specific outcomes or health scores than alternatives not including inpatient rehabilitation. Given the substantial cost differences, better value alternatives should be considered for patients after uncomplicated TKA.