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Atlas charts course to improved care

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The first detailed national appraisal of variations in health practice has found that Australians are among the world’s heaviest users of antibiotics and antidepressants, and within the country there are major differences in the use of common drugs and treatments for everything from colonoscopies and cataract surgery to antipsychotic medicines for the elderly and hyperactivity drugs for the young.

In what is seen as the first step toward addressing unwarranted variations in the care patients receive, the Australian Commission on Safety and Quality in Healthcare has released a report identifying wide discrepancies in the use of everyday medicines and procedures.

Among its findings, the Australian Atlas of Healthcare Variation has revealed that children in some parts of the country, particularly in NSW, are seven times more likely to be prescribed drugs for ADHD than those in other areas, while cataract surgery, hysterectomies, tonsillectomies were three times more common in some areas than others, and patients in some parts were 30 times more likely to undergo a colonoscopy.

AMA President Professor Brian Owler said that, by reflecting how the delivery of health care was organised, the Atlas provided a useful illustration of differences in access to care.

But he highlighted the fact that the Commission itself made no claim about the degree to which differences in care was unwarranted.

“The Atlas is a welcome starting point for further research and examination of health service distribution,” Professor Owler said. “It is not proof that unnecessary or wasteful care is being provided to Australians, and should not be interpreted that way.”

The Commission said that some variation was “desirable and warranted” to the extent that it reflected differences in preferences and the need for care.

It added that “it is not possible at this time to conclude what proportion of this variation is unwarranted, or to comment on the relative performance of health services and clinicians in one area compared with another”.

Senior clinical adviser to the Commission, Professor Anne Duggan, said the average frequency of various services and procedures provided in the Atlas were not necessarily the ideal, and observed that “high or low rates are not necessarily good or bad”.

Nonetheless, she said the weight of local and international evidence suggested much of the differences observed was likely to be unwarranted.

“It may reflect differences in clinicians’ practices, in the organisation of health care, and in people’s access to services,” Professor Duggan said. “It may also reflect poor-quality care that is not in accordance with evidence-based practice.”

Many of the variations identified in the Atlas have been linked to wealth and reduced access to health care in disadvantaged areas.

Professor Duggan said the less well-off tended to have poorer health and so a greater need for care, while some procedures are used more often in wealthier areas.

She said the Atlas showed that rates of cataract surgery were lowest in areas of disadvantage, and increased in better-off locales.

But Professor Owler said the example showed the need to be very careful in drawing conclusions about the reasons for variation.

He said the Atlas showed that the incidence of cataract surgery was highest in the remotest parts of far north Queensland.

“This is because there are no public services available, with private ophthalmologists delivering eye care to Indigenous communities, which is covered by Medicare,” the AMA President said.

He said identifying variation in health care was essential, but this was the first step before determining the causes of variation.

“The Atlas doesn’t tell us what should be the best rates for different interventions and treatments.”

In addition to identifying variations in health care within the country, the Atlas also explored how the care provided in Australia compared internationally.

While acknowledging that differences in the type and quality of data made it difficult to draw direct comparisons, the Atlas nonetheless reported that Australia has “very high” rates of antibiotic use compared with some countries, and Professor Duggan said that, among rich countries, Australia was second only to Iceland in the extant of use of antidepressants.

Professor Owler said that, with the publication of the Atlas, the challenge now was to develop a process to identify variations in practice that were “actually unwarranted, not just assumed to be” and to develop and fund strategies to reduce them by supporting clinically appropriate care, such as by providing clinical services where they are needed.

To view the Atlas, visit: http://www.safetyandquality.gov.au/atlas/

Adrian Rollins