Variation in medical practice: are Australians getting world-class health care?
Professor Anne Duggan, Senior Medical Adviser, Australian Commission on Safety and Quality in Health Care
Dr Rob Grenfell, Director of Cardiovascular Health, Heart Foundation
Professor Michael Buist, Chair of Health Services, School of Medicine, University of Tasmania
Revelations of major discrepancies in the treatment provided to patients with similar conditions but living in different areas formed the backdrop for a detailed discussion of variation in medical practice at the AMA National Conference.
Senior Medical Adviser to the Australian Commission on Safety and Quality in Health Care, Professor Anne Duggan, told the Conference that an investigation into medical practice variation in Australia had found patients in some areas of the country were more than seven times as likely to undergo cardiac catheterisation as those living in other areas, while the variation was up to 11-fold for knee arthroscopy and four times for hip replacements.
The findings, part of a joint Commission/Australian Institute of Health and Welfare report (see http://www.safetyandquality.gov.au/publications/exploring-healthcare-variation-in-australia/), were echoed in data presented to the conference by the Heart Foundation’s Director of Cardiovascular Health, Dr Rob Grenfell.
Dr Grenfell said figures provided by Victorian hospitals showed that up to a third of patients who had suffered a myocardial infarction needed to be readmitted to hospital.
While the tendency of patients to stop taking their medication after a couple of years was part of the problem, research also showed that a significant proportion were not given the medication they needed when they were discharged, and there were inconsistent care plans.
“I often comment that the correct term for patients should in fact be punters,” Dr Grenfell told the Conference. “I would be worried about family members with heart failure as to what care they may receive.”
Such evidence has raised concerns about how health care is delivered, including equity of access to care, the extent to which advances in treatment are adapted and adopted, as well as the lack of a system to monitor the outcome of common treatments.
In a forthright presentation to the Conference, Chair of Health Services at the University of Tasmania, Professor Michael Buist, highlighted the prevalence of preventable human error in clinical care.
He cited a 1999 study showing that 11 per cent of patients died because of the failure of hospital staff to attend, while other fatalities were attributed to an inability to following procedure, absentmindedness, “cognitive failure” and other shortcomings.
Professor Buist clinicians needed to look at patients as people, while hospital quality and safety units needed to engage with clinicians, particularly junior doctors and nurses.
Professor Duggan said that while “not all” variation in treatment was problematic, and in fact could be due to differences in population, patient preferences and practise innovation, there were obviously many instances where it was unwarranted and signalled possible problems including inappropriate care, safety and quality issues or inadequate resources.
AMA Vice President Dr Stephen Parnis, who chaired the session, said the practice of medicine was often fraught with uncertainty, and part of the “art of medicine is to use one’s professional training, skills and experience to deal with that uncertainty”.
Dr Parnis said that “dealing with unwarranted variation in practise can set the course for cost containment and improving safety and quality”.
Dr Grenfell said there needed to be better and more accurate data collection regarding treatment and outcomes, including tracking readmissions.
He said the focus of reform also had to change.
“We have had a financial reform agenda [in health], not a clinical reform agenda. We need a focus on actual clinical improvement, empowering clinicians and, hopefully, patients to drive change,” Dr Grenfell said.