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There are many established health care practices and an ever increasing number of advances that unequivocally represent value for money. However, we hear daily about unacceptable delays for public patients in access to both established and new high-value interventions.
As quality improvement (QI) activities consume resources and do not provide direct clinical care, it has been suggested that resources be diverted from QI to fund more clinical care.
There would be a powerful argument for this if clinical care was appropriate and properly delivered, and if all QI activities were futile and did not improve care or outcomes. However, neither is the case.
Much clinical care is neither appropriate nor properly delivered. For common conditions for which evidence is available, patients receive appropriate care only about half the time, with enormous regional variations.
In the US, the quintile of the population that consumes 50% more health care resources per person than the lowest quintile does not have better outcomes or better perceptions of their care. On top of this, at least 10% of admissions to acute care hospitals are associated with health care-associated harm, as are over a million general practice consultations each year in Australia.
This is not a “good look” for a health care system that costs over $100 billion per year (nearly 10% of gross domestic product), and which is on a trajectory to becoming unaffordable.
Diverting funds to “more of the same” will produce more of the same.
With an ageing population and ever-increasing possibilities and expectations, there is an urgent need to provide rational care and redirect funding from ineffective or non-cost effective practices. Continuing to fund inappropriate care and substandard practices automatically while denying high-value appropriate care to many of those in need represents institutionalised unethical practice.
Well designed QI activities do not fail to deliver on improved care or outcomes; indeed, many represent remarkable value for money.
Proper implementation of a “central venous line” care bundle can sustainably virtually eliminate deaths from catheter-related bloodstream infections. The effective use of surgical checklists can reduce perioperative morbidity by a third and mortality by nearly half — potentially saving tens of thousands of lives each year in Australia.
What is really remarkable is that uptake of these fairly straightforward interventions has been slow and patchy in Australia, opposed with the usual mantras about recipe-book medicine, erosion of clinical autonomy, and patients, contexts and practices somehow being different.
There is no doubt that much QI activity has failed to use rigorous methods and has resulted in a plethora of poorly designed, underpowered local projects which lack credibility and have little impact on clinical practice.
However, this should not lead to the reflex dismissal of all QI activities.
The real problem is that current practices in both clinical care and QI are often deeply flawed. There are inherent difficulties in QI and health services research that underlie the general lack of progress.
These have been summarised recently, and a carefully argued case made for the use of process as well as outcome measures, ideally incorporated into randomised cluster or stepped-wedge research designs.
Another well argued approach is to develop national clinical registries to “target conditions or procedures … associated with large variations in processes or outcomes of care … that impact significantly on healthcare costs and patient morbidity”.
Whether the approach taken is population-based, condition-based or both, national level research involving both public and private patients across all health care settings is needed. We need to be able to determine, on an ongoing basis, who is getting what care from whom and why, to decide what constitutes appropriate care and to develop clinical standards and tools to apply them.
Like the examples cited above for central lines and surgery, the tools need to reflect clinical standards (either implicitly or explicitly), to constitute the mechanism by which compliance is documented, and allow easy audit (preferably electronic) that should form the basis for credentialling of individual clinicians and accreditation of health care services.
Much needs to be done in retiring inappropriate care and ineffective QI; we simply cannot afford more of the same. The need for national clinical standards — for the meshing of QI and clinical care in our nationally funded system — is urgent.
Inappropriate care and ineffective QI should not be funded.
The money currently wasted would be better spent on creating a new amalgam of evidence-based care with built-in QI.
The need for health care to be based on sound doctor–patient relationships will remain but should be built on a foundation of both getting the basics right and being seen to do so.
Professor Bill Runciman is professor of patient safety and healthcare human factors in the School of Psychology, Social Work and Social Policy at the University of South Australia.
This Opposing Views article appears in the MJA. It is reproduced with permission of the MJA. Please click here to read the opposing view by Dr Alasdair Millar.
Posted 20 June 2011
Endless QI is sometimes an excuse for doing nothing; or worse still, as in the case of child abuse and child death, much more attention is given to the case, or to a failure of a health care delivery system after the fact of child death and abuse or iatrogenic injury than before the occurrence, when action could have saved the life of a child or prevented a serious medical mishap. Let’s get the timing and allocation of resources right – PREVENTION!
I’d wish people would stop quoting figures of US health outcomes in order to justify funding decisions in Australia. Australia has a vastly better average health outcome than the US at vastly less cost, and the health systems are vastly different – it stands to reason to assume until proven otherwise that we cannot easily derive conclusions on how to improve our own system by looking at theirs other than preventing their mistakes (while sadly our health politicians seem to do the exact opposite).
The improvements of QI, or the “failures” of routine health services may not be what they look on paper. We all know that statistics lie, statistics can be made to “show” whatever we like, intentionally or subconsciously. Evidence-based approaches are only “proven” for patients matching the inclusion criteria of the studies that provided the “evidence” – please let’s not forget that real life patients are often very different beasts from the highly selected herd included in studies, and hence the derived “EBM” might not be best practice for those at all.
What counts, at the end of the day, is how many patients make it to old age in good enough health to remain happily independent. Australia is not faring all that bad in that regard, and I have seen very little evidence that most expensive QI incentives (except for the ones improving simple hygiene, eg, hand washing that really work) here have provided much value for money to improve said real world outcome as opposed to paper figure improvements. Happy to learn different though.
Will more doctors increase or decrease death rates?
Professor Jeff Richardson and Dr Stuart Peacock explored the relationship between supply of medical doctors and wellness… their econometric results using Australian cross-sectional data are are consistent with the hypothesis that an increase in the doctor supply is associated with an increase in mortality – http://www.buseco.monash.edu.au/centres/che/pubs/wp137.pdf
QI is another bureaucratic monster with an insatiable appetite. If allowed to grow unhindered it will further compromise our ability to deliver quality medical care.
We are all interested in QI(Quality Improvement) but this is often at the expense of good team work (staff relationships). Money and time is wasted on staff and patient satisfaction surveys.
“Analysis paralysis” was a term I first heard from a previous Queensland State Labor treasurer, very descriptive of what goes on in the workplace.