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Preference: Administration and Health Services

2

Domestic violence victims urged: talk to your doctor

Women suffering violence at the hands of their partners are being encouraged to speak with their family doctor amid concerns that many are failing to get the support they need.

AMA President Professor Brian Owler has joined with Australian of the Year Rosie Batty and AMA New South Wales President Dr Saxon Smith in launching the Share your story campaign to encourage victims of domestic violence to speak with their GP.

Professor Owler said doctors were at the domestic violence frontline, and saw the consequences of the physical and emotional abuse of women and children as part of their daily work.

“I remember when I started as a neurosurgeon at the Children’s Hospital at Westmead, I was shocked – and in fact still am shocked – , at the number of cases that we deal with, the proportion of our work that is taken up with severe head injuries, devastating consequences of domestic violence,” the AMA President said. “Some of them die in hospital; the vast majority end up with severe disability and are in need of lifelong care”.

Ms Batty said the nation needed to do more to protect children from family violence.

“How does a child recover from the trauma of injury, psychological abuse, sexual abuse? How do they lead a life as adults when they are permanently affected by the trauma of being impacted by violence in their families?” she said. “The children are the future, and we are not doing a good enough job.

Ms Batty said that doctors had a big role in helping women in need.

Professor Owler said familiarity with the family doctor often made them the first port of call for those suffering abuse at home, even more so than specialist care.

“Everyone knows where to go if they want to see a doctor, but that’s not always the case with domestic violence services,” he said. “Domestic violence services are certainly there and ready to help, but they can be less visible than doctors in the community.”

The Share your story campaign is complemented by a program to assist family doctors in identifying and supporting patients suffering domestic violence. Earlier this year the AMA joined with the Law Council of Australia in producing a guide for doctors in how to broach the issue of domestic violence with their patients, both victims and perpetrators, as well as canvassing legal obligations and detailing support services.

The AMA President said that the ability to provide support and find appropriate help was “a vital role that doctors, nurses, care workers play, both in helping to identify, but also in trying to support victims – whether they’re women or children or anyone else, that are victims of this scourge in our community”.

At the launch, Professor Owler sought to draw particular attention to the plight of children, who he said often suffered lifelong effects of domestic violence.

“We see large numbers of children that present through our hospitals that unfortunately are victims of domestic violence, and they have a range of injuries, including head injuries, eye injuries and fractures, [that can] have a devastating impact on the rest of their lives,” the AMA President said.

He said non-accidental head injury, usually resulting in bleeding on the brain, was “very common” among children growing up in abusive households, and could lead to severe disability or other life-long impediments such as epilepsy and poor emotional control.

 “The other side of this is…that we have children that are just exposed to domestic violence or abuse, and that can have significant consequences as well, particularly from psychological perspectives.”

Between 2008 and 2010, 29 children were killed by a parent or step-parent, and Professor Owler said abuse by a parent or step-parent was the third most common cause of injury in children, after car accidents and accidental drowning.

 Adrian Rollins

Dedicated service major advance in doctor health

The AMA is on target to establish a national network of dedicated doctor health services by the end of 2016, Vice President Dr Stephen Parnis has revealed.

In a major speech to the biennial Australasian Doctors’ Health Conference, Dr Parnis said the establishment of the network was a “very significant and positive initiative” that would boost the level of support to the profession.

Focus on the health of doctors, particularly their mental wellbeing, has intensified in recent years amid mounting concerns around very long and disruptive work hours, substance abuse, and workplace bullying and harassment.

The issue of workplace bullying and harassment has come in for particular attention in recent months after vascular surgeon Dr Gabrielle McMullin complained that female trainees were being pressured for sex by senior surgeons.

A survey of 3500 people subsequently conducted by the Royal Australasian College of Surgeons found about half of surgeons, trainees and international graduates had suffered some form of abuse. In all, around 60 per cent of women reported they had been bullied and around 30 per cent said they had been sexually harassed.

Dr Parnis told the Conference that he had personal experience of the many serious stressors doctors face during their working life, and the growing willingness to acknowledge and address them was a welcome development.

“I have been an advanced trainee in surgery, and I have had personal experience of some of the issues uncovered this year,” the Vice President said.

“I have sought the advice and care of medical colleagues when I have found the pressures of my career overwhelming [and] I have grieved for friends and colleagues who have harmed themselves or taken their own life.”

Dr Parnis told the Conference that, rather than indulging in a culture of finger-pointing and blame, the medical profession needed to promote good health and health lifestyles for its members.

He said the establishment of a national network of dedicated doctor health services was an important part of this process.

The Medical Board of Australia is providing the AMA $2 million a year, indexed to inflation, to establish and oversee a nationally consistent suite of health, advice and referral services for doctors and medical students available in all states and territories.

To deliver this, the AMA has created Doctors’ Health Services Pty Ltd, a wholly-owned subsidiary, to co-ordinate the delivery of services that are at arm’s length from the Medical Board.

An Expert Advisory Council, chaired by Dr Kym Jenkins of the Victorian Doctors’ Health Program and including representatives of existing health services, medical students and doctors in training, will help guide its development and operations.

Dr Parnis said the development of the national service was “progressing well, and the programs are on target to be operational by the end of next year”.

“We will all end up being a patient at times during our career, and the challenge is to practise what we preach to our own patients,” the Vice President said. “We need to be honest, to be open to uncomfortable advice from our doctors, and to recognise our own limitations.”

He said the development of the national doctor health service was “a very significant and positive initiative” that would boost the support available to doctors.

“To care for one’s colleagues is not an easy thing, because it entails significant risk,” Dr Parnis said, “but there are real rewards and satisfaction for those who do.”

Adrian Rollins

 

Australasian Doctors’ Health Conference 2015

By Dr Kym Jenkins, Conference convenor and Medical Director, Victorian Doctors’ Health Program

Doctors’ health, and the health of the medical profession more generally, has never been more in the news.

Through both the general media, and specialised medical publications, we have been hearing all too frequently of toxic workplaces, bullying and harassment. Stories of individual doctors who have “stuffed up”, or who are struggling, seem to make good headlines.

The Australasian Doctors’ Health Conference 2015 (adhc2015), held 22 -24 October, with its theme of “Pathways and Progress”, sought to address and redress these issues.

The conference focussed on extending the debate beyond what is wrong with our profession and just delineating the health issues we face, to a demonstration of what can be done to improve things and an examination of how individuals and organisations have overcome adversity to improve health outcomes.

The Australasian Doctors’ Health Conference is biennial event, and is an initiative of the Australasian Doctors’ Health Network. This year, the Victorian Doctors’ Health Program was proud to host the conference, and I was privileged to be its convenor.

The selection of invited speakers reflected both the breadth and depth of issues regarding wellbeing currently facing the medical profession.

Associate Professor Jan Mckenzie, a consultant psychiatrist and Associate Dean at the University of Otago, gave a moving description of how the Christchurch earthquake affected the lives of students, teachers and administrators at the University of Otago medical school.

Somehow, in the midst of the devastation, and despite the lack of electricity, a functioning IT system or functional buildings, the teaching continued. Although Jan and her colleagues live in homes that still await rebuilding, they not only support their students but have managed to produce a study with case-controlled data on the educational outcomes for Christchurch students, which has helped identify factors that have led to better outcomes.

Professor Carmelle Pesiah, Professor at the University of New South Wales, provided an entertaining (and, for some, shocking) insight into doctor aging. Professor Pesiah delivered some very strong messages and salutary warnings for us all as we get older. She emphasised that there is not just one formula for successfully aging and negotiating the approach to retirement. Aging with a little disgrace may increasingly be the norm.

Dr Hilton Koppe, a general practitioner and medical educator from Lennox Head explored what makes a career in medicine fulfilling. Dr Koppe was an innovative and engaging teacher, and his presentation encouraged people to challenge their perceptions.

On day two of the Conference, Sydney-based psychiatrist and addiction specialist Associate Professor Stephen Jurd spoke on the Doctors Recovery Movement. In a very inspirational presentation, Professor Jurd disavowed those present of any doubt that addiction is an illness. He highlighted the challenges for doctors overcoming addictions, demonstrated the power of recovery and is himself living embodiment of how much our profession will lose if we do not support for medical professionals in their recovery.  

The system of mandatory reporting of impairment in doctors was the focus of a presentation from public health physician and health lawyer Dr Marie Bismark, who informed her presentation with data she has obtained from the Australian Health Practitioners Regulation Agency.

The program of free papers, seminars and workshops throughout the two days likewise stimulated much debate, discussion and sharing of initiatives to make ourselves and our workplaces healthier.

The academic program concluded with a “Hypothetical” in which former Alfred Hospital General Counsel Bill O’Shea quizzed and challenged a team of experts about the multiple issues raised in a (not so) hypothetical case of a doctor found using propofol in the workplace.

The need to consider and look of after the individual doctor was apparent, as were the effects on the doctor’s colleagues and the workplace, and the issues of mandatory reporting.

The hypothetical demonstrated the need to take a systems view when a doctor is impaired in the workplace, and to bring together the multiple agencies involved: in this case, the general practitioner, addiction specialist, hospital administration, the Doctors’ Health Program, representatives from the doctor’s own specialist college, and the provision of support services for the colleagues – including a registrar and a medical student – traumatised after finding the doctor unconscious and apparently intoxicated.

Healthy doctors and a healthy profession – a personal reflection

By Dr Kym Jenkins, Conference convenor and Medical Director, Victorian Doctors’ Health Program

The Australasian Doctors’ Health Conference 2015 left me with three take-home messages regarding the health of doctors and the wellbeing of the medical profession. These were:

1. the importance of diversity within the medical profession. That for the medical profession to be healthy, we need not only doctors with different personality styles, but doctors from diverse cultural backgrounds and ethnicities, whatever their sexuality and gender;

2. the importance of being something or doing something other than being a doctor: what we do when we’re not practising medicine not only refreshes and rejuvenates us, but enriches us as human beings and, as a consequence, enriches us as doctors; and

3. the importance of a sense of connection. Isolation is not good for doctor health. Connections to our workplace, to our craft group, to our colleagues, to a learned College or a professional group, or to an individual such as a mentor, are all protective factors for keeping us healthy.

adhc2015 fulfilled its ambition in help make discussion about the need to keep ourselves and our profession healthy well and truly open. In 2015, taking an interest in doctor health is no longer seen as a frivolous or non-essential activity. There is an increasing body of work in this area and much more is still needed.

The next Australasian Doctors Health conference will be in in Sydney in 2017.

 

Hospitals, health workers increasingly targeted as conventions break down

A wave of deadly attacks on hospitals and health workers in Middle East conflicts has fuelled fears that basic conventions against targeting medical and humanitarian services in war zones are breaking down.

United Nations Secretary General Ban Ki-moon has denounced what calls “the brazen and brutal erosion of respect for international humanitarian law.”

“These violations have become so routine there is a risk people will think that the deliberate bombing of civilians, the targeting of humanitarian and health care workers, and attacks on schools, hospitals and places of worship are an inevitable result of conflict,” he said.

Mr Bann called for action to be taken against those responsible.

“International humanitarian law is being flouted on a global scale,” Ban said. “The international community is failing to hold perpetrators to account.”

A senior Medical charity Medicins Sans Frontieres (MSF) official has warned that the concept of international humanitarian law may be “dead” after a hospital operated by the organisation was destroyed in a bombing attack by Saudi-led forces operating in Yemen – the second such attack in less than a month.

MSF said that on 26 October its hospital in Haydan was destroyed by air strikes carried out by the Saudi Arabia-led coalition fighting against Houthi forces in the war-torn Middle East country. Multiple casualties were only avoided by the rapid evacuation of patients and medical staff.

The attack came just weeks after United States forces bombed an MSF hospital in north-east Afghanistan, killing 22 people including 12 medical staff.

And the charity has reported that at least 35 patients and medical workers have been killed, and 72 wounded, following an escalation of air bombing raids in northern Syria.

It said 12 hospitals have been hit in the Idlib, Aleppo and Hama governorates in the past month, causing six to close and destroying four ambulances.

Head of MSF operations in Syria, Sylvain Groulx, said calls for an immediate halt to such attacks had so far fallen on deaf ears.

“After more than four years of war, I remain flabbergasted at how international humanitarian law can be so easily flouted by all parties to this conflict,” Mr Groulx said. “We can only wonder whether this concept is dead.”

Pressure is mounting on the United States Government to agree to an independent inquiry into its attack on the MSF hospital in the Afghan city of Kunduz.

The International Humanitarian Fact-Finding Commission (IHFFC), established under the Geneva Conventions, has written to both the US and Afghanistan governments to offer its services for an independent inquiry following a complaint from MSF.

US President Barack Obama has issued a public apology for the bombing, and his Government has initiated its own inquiry. But Mr Obama has been steadfast in resisting calls for arms-length investigation, and is considered unlikely to accept the Commission’s offer.

Neither the US nor Afghanistan are member states of the Commission, which has no power to compel their participation.

“It is for the concerned Governments to decide whether they wish to rely on the IHFFC,” the Commission said. “The IHFFC can only act based on the consent of the concerned State or States”.

President Obama has assured that his Government would conduct a “transparent, thorough and objective” inquiry into the tragedy.

But MSF claims the attack could amount to a war crime and must be investigated independently.

“We have received apologies and condolences, but this is not enough. We are still in the dark about why a well-known hospital full of patients and medical staff was repeatedly bombarded for more than an hour,” said Dr Joanne Liu, MSF International President. “We need to understand what happened and why.”

Dr Liu said her organisation was determined to uncover how the attack had occurred, and to hold those responsible to account.

“If we let this go, as if it was a non-event, we are basically giving a blank cheque to any countries who are at war,” Dr Liu said. “If we don’t safeguard that medical space for us to do our activities, then it is impossible to work in other contexts like Syria, South Sudan, like Yemen.

Saudi authorities have denied responsibility for the Yemen hospital attack, though it has been reported that Saudi Arabia’s ambassador to the UN has blamed MSF for providing incorrect GPS coordinates to the Saudi-led coalition – a claim the charity denies.

MSF said it provided Saudi-led armed forces with details of the hospital’s location on multiple occasions, including just two days before the strike that destroyed the facility.

President Obama called Dr Liu to apologise for the attack after the US military admitted responsibility.

The Kunduz hospital attack occurred despite the fact that MSF had given all warring parties the GPS coordinates of the hospital.

Outrage over the attack was heightened when the US initially appeared to claim it was a necessary and legitimate use of force, before later characterising it as a mistake.

MSF said that “any statement implying that Afghan and US forces knowingly targeted a fully functioning hospital – with more than 180 staff and patients inside – razing it to the ground, would be tantamount to an admission of a war crime,” MSF Australia President Dr Stewart Condon and Executive Director Paul McPhun said. “There can be no justification for this abhorrent attack.”

“Medecins Sans Frontieres reiterates its demand for a full, transparent and independent international investigation to provide answers and accountability to those impacted by this tragic event.”

Adrian Rollins

My journey from suit to skin

Winner

As my Aunty placed the possum skin cloak over me, I experienced a profound “inner experience” of cultural healing and connection. Wearing the cloak as part of the Wrapture project (http://www.speakingincolour.com.au/wrapture) restored an aspect of cultural traditional practice. It touched me holistically, creating a sense of healing, spiritual connection, belonging and identity.1

The project was a photographic exhibition for Aboriginal women of the Hunter region in New South Wales, facilitated by my cousin.2 She gathered close members of the family at my Aunty’s house to help her search for women to participate. Within a 9-week time frame, over 130 Aboriginal women wearing the possum skin cloak were photographed, capturing the first few moments of cultural revival connection. The project served as a platform for a dialogue on “women’s business” (traditional cultural practice exclusive to Indigenous women) and, within a few months, 64 Aboriginal women were included in the exhibition which was launched at the Wollotuka Institute at the University of Newcastle in NSW. The significance for me is that before Western influence, we were all born with a possum skin cloak or other cloaks such as kangaroo skin that grew in size with us, just as a child grows into adulthood. After my Aunty placed the cloak over me she took a step back. Then my cousin stepped forward to capture my initial reactions through the camera lens. It was a journey that took me through a number of mixed emotions. Grief and loss rushed through me as it initially felt foreign. Then I felt a spiritual connection — I became teary, embracing the possum skin cloak.

Community development initiatives, such as the Wrapture project, gather Aboriginal women to harness cultural reconnection and pride in identity. This concept, and its connection to self-determination, wholeness and wellbeing, is reflected in the law/lore that states: “We walk our journey boss of self. So take your power, walk your talk, seek your truth and be your journey and hopefully when you die, you die boss of self”.3 This illustrates the cyclical aspect of life–death–life, which adopts a whole-of-life approach.4

I had the opportunity to play a role in reviving and reconnecting with the possum skin cloak, inviting my journey to be captured in a photograph. It was spiritually and emotionally moving to reconnect with an ancient cultural traditional practice. Reflecting on this “inner journey” revealed to me another journey; an “outer journey” in a small country town many years before, in a high school textile and design class. In this class, I decided to make a business suit — one that I could wear during my 2-week work experience. My teacher brought an old design she had from home and helped me put it all together, appearing even more enthusiastic than I was when we completed this project. During the months spent constructing the suit we had built up a close relationship.

However, my teacher had more in mind for me than the making of this suit. She worked with me, a shy, reserved young Aboriginal student, helping me to recognise a sense of pride in myself and to form a sense of my own identity. Later, in Year 12, I remember her handing me an application form for the University of Sydney. She encouraged me to apply, and even helped me fill out the form. I had no comprehension of the journey I was about to embark upon.

This journey led me to the understanding of the power of community development and education as tools in developing a sense of self-belief. Being offered a place at the University of Sydney was a significant achievement, not only for me but also my family. I was the first in my family to complete high school and obtain a university degree. The connection between health and access to education for me, personally, as an Aboriginal person, is reflected in the literature on the positive relationship between performance and retention in formal education and participation in the arts.5

My understanding of the importance of addressing health equity and access to improve health outcomes for Aboriginal Australians began to develop when I was at university. I was selected, along with a small group of other Aboriginal students, to provide mentoring for Aboriginal high school students coming to the university from rural and remote areas of NSW. I watched the students explore their first taste of university in a culturally safe and supportive environment. Being a part of this was enriching and it brought me back to cultural connectedness.

Since then I have completed a Bachelor of Arts degree and I am now doing a postgraduate course in public sector management. The importance of access to health and education, and the positive health outcomes for Aboriginal Australians is reflected in my current position as Policy Analyst at NSW Kids and Families. I am supported and mentored to complete my postgraduate studies so I can pursue professional development while also maintaining a holistic lifestyle. My 8-year-old son often asks, “Is it essay time yet, Mum?”. My study has produced positive role modelling for my children, who see me maintaining full-time employment while engaging in a university course. In 2014, I was a guest speaker to students in the university’s Australian Indigenous Mentoring Experience (AIME) program. I was asked to speak about my journey, about leaving my home and family to study for a university degree in Sydney. We shared stories in the hope of inspiring students in the AIME program to remain in high school and pursue tertiary studies.

The ability to combine community development and employment was central to building and maintaining my cultural connectedness. Over the past 5 years, I have worked as an Aboriginal Health Worker for the Aboriginal Maternal Child and Family Health Services in rural and metropolitan areas of NSW. It was a gratifying role, allowing sustained cultural connectedness with my community and people, while also promoting employment opportunities. Learning that my efforts in this role played a small part in closing the gap in infant death rates between Aboriginal and non-Aboriginal people,6 I felt this was a positive step forward for our children, our future generation. The Aboriginal Maternal Child and Family Health Services has a strong emphasis on community development and health promotion. This is one of the most fulfilling aspects of working as an Aboriginal Health Worker — linking health promotion and community participation. It was a privilege to be welcomed into the homes and lives of clients and community members as a NSW Health employee, and accomplish self-fulfilment through work.

Community development requires a deep understanding of local community needs and community ownership of health programs. I have learned the hard way. One very strong memory is when I suddenly arrived at a local Elder’s group and talked for 30 minutes non-stop, discussing women’s business issues, using the women’s health charts and other health educational material. It was then time for the group to comment. The room went completely quiet. I knew immediately that I had failed! I left the group feeling disheartened; I had not been able to culturally connect with the group — instead I had been pushing my own agenda.

A week later, I returned, deciding to take a different approach. I walked to the group, sat down and let the conversation evolve naturally, just “being”. Within 20 minutes, one Aunty asked me how my child was going. Conversation then flowed around sharing of stories, tea and johnnycakes. Towards the end, another Aunty asked me, “So what was that thing you were going on about?”. We have a few laughs about it to this day, and I learned a very important lesson from that experience about community development.

I have also been involved in a belly casting project. This brought me, as an Aboriginal Health Worker, to a deep understanding of the importance of connecting with family and the journey in pregnancy and maternal health. I carried my “belly cast kit” from home visit to home visit, meeting with pregnant women and extended family members, and building relationships with the community. Doing the belly casts opened an intimate dialogue around women’s business, raising issues in health and education, cultural connection and support, as well as canvassing the needs of the individual, and then the family and community. Some women had lost their cultural identity or connections, and the belly casting enabled a journey toward reconnection to cultural identity. I used my connections as an Aboriginal Health Worker within interagency networks across government and non-government departments to assist this journey. Attendance at antenatal clinics is unlikely to facilitate the depth of these discussions. This highlights the importance of community development approaches in providing positive pathways for access and equity.

Most successful community development activities in NSW Health programs adopt a primary health care model, prioritising a holistic framework to build positive health and wellbeing for Aboriginal Australians. In contrast to a biomedical model’s focus on symptomatology and illness,7 the primary health care approach incorporates the interconnectedness of health and wellbeing through a tapestry involving self and identity, family, community, land, kinship, ancestral and spiritual dimensions.8 Community development deployed through arts programs can be defined as “a specific approach to creative activity that connects artists and local communities in using arts as a means of expression and development”.5

The social determinants of health impede positive health outcomes for Aboriginal Australians. Disadvantage accumulates and is compounded through life experiences (such as racism and poverty) which transfers trans-generationally, leading to social, economic and cultural inequality.9 Community development and empowerment serve to address these inequalities experienced by Aboriginal Australians.

My journey from suit to skin highlights the importance of equity and access for Aboriginal health. I have had the privilege of learning from the best knowledge holders, my Elders. One significant aspect of this is walking through my own journey to health equality and access, which has created positive health outcomes. In the words of an Aboriginal senior woman, educator and healer, “we cannot walk somebody else’s journey nor sway them to walk ours. They must walk their own”.3 My journey shows that the cumulative cycle of disadvantage can be combated by a cycle of advantage. As my Elders, my family, special people such as my high school teacher and my colleagues, have supported me, I can, in turn, better support my family and Aboriginal community. Through acknowledging this cultural aspect of health, community development facilitates the building of relationships outside the traditional models of health care, leading to empowerment and capacity building in knowledge.

Continuous quality improvement and metabolic screening during pregnancy at primary health centres attended by Aboriginal and Torres Strait Islander women

Attending to perinatal risk factors, such as diabetes and hypertension during pregnancy, obesity and excess gestational weight gain,1–5 is important for optimising maternal and infant health outcomes. Pregnancy is also a key period for implementing strategies that prevent long-term adverse health outcomes, as excess gestational weight gain and gestational diabetes mellitus (GDM) are respectively predictors of long-term obesity6 and the development of type 2 diabetes.7

Screening for and follow-up of metabolic risk factors are components of recommended pregnancy care in Australia.8 Ensuring that Aboriginal and Torres Strait Islander (respectfully referred to in this article as Indigenous) women receive such care is expected to contribute to giving babies a healthy start to life and to improving the health of their mothers. In Australia, low birth weight, premature birth and perinatal death are substantially more frequent in Indigenous than in non-Indigenous pregnancies.9 Obesity, pre-existing diabetes and GDM are some of the risk factors that are more common in Indigenous women.3,4,10 Later in life, cardiovascular disease and diabetes are major contributors to the difference in life expectancy between Indigenous and non-Indigenous Australians.11

As care can differ between health centres with different characteristics, such as urban and rural or remote locations,8 effective long-term strategies are needed across a range of settings to facilitate the provision of all components of recommended pregnancy care.12 The Audit and Best Practice for Chronic Disease (ABCD) National Research Partnership13,14 aims to improve the provision of care by primary health care centres (PHCs) serving mainly Indigenous populations. It uses a continuous quality improvement (CQI) framework to increase the efficiency and effectiveness of organisational systems. Previous ABCD Partnership research indicates that increases in self-ratings of organisational systems are associated with improvements in the delivery of health care for those with type 2 diabetes.15

We investigated screening for metabolic risk factors during pregnancy and follow-up actions by PHCs participating in the ABCD partnership. We also investigated associations between self-ratings by organisational systems and the proportion of women who undergo metabolic screening.

Methods

The study was approved by human research ethics committees in the relevant states and territories, and by Indigenous subcommittees where required.16 The analyses were approved by the Monash University Human Research Ethics Committee (CF12/3434-2012001670).

Study design and setting

The ABCD National Research Partnership study protocol has been described in detail elsewhere.13,16 This partnership links multiple PHCs and stakeholders across the health system in collaborative CQI research.14 One21seventy, the National Centre for Quality Improvement in Indigenous Primary Health Care, supports CQI in PHCs by providing evidence-based practical tools and training.14 The ABCD Partnership has access to One21seventy data from PHCs that have volunteered to participate in research.13,14 This article reports longitudinal analysis of data from 76 PHCs (2592 health records) involved in the ABCD Partnership across five Australian states and territories. The PHCs conducted up to four CQI cycles, comprising 58.5% (168 of 287) of the One21seventy maternal health audits conducted between 2007 and 2012. Twenty-one of the 76 PHCs began maternal health auditing in 2007; 13 commenced in 2008, 13 in 2009, 11 in 2010, 10 in 2011, and 8 in 2012. Depending on their needs, PHCs may focus in some years on CQI activities in other clinical areas; of 50 PHCs that had completed two or more maternal health audits, 11 (22.0%) conducted audits in non-consecutive years.

Intervention: continuous quality improvement cycles

At baseline, systems assessments and audits of health records were conducted and the results provided to PHCs in real-time by an automated CQI reporting system. PHCs use the reports for participatory interpretation and goal setting, and this is followed by the initiation of relevant actions. Data collection was repeated in subsequent years to assess success in improving care (end of cycle 1), and to identify new priorities for improvement (start of cycle 2). PHCs are encouraged to complete one cycle each year.

Maternal health audit tool

Recorded pregnancy care was assessed by auditing the health records of women with a recent pregnancy (mothers with an infant aged 2–14 months, who resided in the community during their pregnancy and attended for pregnancy care at least once).13,16 Audits were conducted by trained auditors (local PHC staff, staff from other PHCs, or CQI facilitators) supported by a standard protocol and regional CQI facilitators. The audit tool and parameters of the outcome measures were based on best practice guidelines, policy and research reports, and stakeholder consultations.16 At each PHC, the auditor used a standard sampling protocol to select a random sample of at least 30 records to audit (if fewer than 30 eligible records were available, all were audited).13

The Systems Assessment Tool

Structured assessments of PHC system strengths and weaknesses were conducted by PHC staff together with a trained external CQI facilitator using the Systems Assessment Tool (SAT).13,15 This consensus process produces a self-reported overall mean score (range, 0–11) for the state of development of PHC organisational systems, and five subscale scores (delivery system design, information systems and decision support, self-management support, external links, and organisational influence and integration).

Key outcome measures

The audit tool collected information on documentation of the following items in each health record:16

  • body weight, body mass index (BMI) and blood pressure (BP) screening in women attending at earlier than 13 weeks’ gestation;

  • BP checks at any point during the pregnancy;

  • a 50 or 75 gram glucose challenge test (GCT) and, if indicated, an oral glucose tolerance test (OGTT) at 20–30 weeks’ gestation;

  • for women with a BMI under 20 or over 30 kg/m2: development of a BMI management plan;

  • for women with high BP (≥ 140/90 mmHg): repeated BP measurements, urine tests for protein, examination by or referral to a general practitioner or obstetrician, or prescription of anti-hypertensive medication;

  • an OGTT for those with an abnormal GCT result (plasma glucose concentration ≥ 7.8 mmol/L 1 hour after a 50 g glucose load (morning, non-fasting), or ≥ 8.0 mmol/L after a 75 g glucose load).

“Follow-up” in this article refers to taking the next appropriate action after an abnormal screening result.

Statistical methods

Analyses were conducted using Stata version 12.1 (StataCorp). P < 0.05 (2-sided) was defined as statistically significant. Differences in screening proportions at baseline and at the final audit were assessed with respect to PHC governance, location, population size (t tests or Mann–Whitney U tests) and state or territory (one-way analysis of variance or Kruskal–Wallis tests). Paired t tests assessed differences between the first and last SAT scores. Using each health record as the unit of analysis, random effects logistic regression analysis (generating odds ratios) assessed any associations between metabolic screening and CQI cycle number (Stata xtlogit command). Random effects logistic regression allowed for repeated measures of each outcome (eg, did a patient receive a BP check: yes or no) at each cycle per PHC. This method also allowed for adjustment for similarities in women within each PHC. The reference group comprised audit data from the PHCs before they had conducted a CQI cycle (ie, cycle 0 or baseline). We also tested for a trend to increased metabolic screening with each additional CQI cycle (Stata nptrend command).

For each PHC, the proportion of women receiving screening after each CQI cycle was calculated. Treating each PHC as the unit of analysis, univariable linear regression (generating β coefficients) assessed associations between:

  • the average proportion of women who underwent screening across all cycles, and average overall or subscale SAT scores;

  • the total change (from first to final cycle) in the proportion of women who underwent screening, and the total change in overall or subscale SAT scores.

Results

A range of PHC settings were included in the study. Most women who attended these PHCs for pregnancy care were Indigenous Australians (87.9%) (Box 1).

While most women who attended during the first trimester were weighed, the BMI was calculated for less than a third; but women attending after the PHC had conducted at least one CQI cycle were more likely to have had their BMI assessed than women attending PHCs that had not done so. Similar patterns were observed for BP checks at any point during the pregnancy and diabetes screening. Improvements in screening appeared to be sustained over sequential CQI cycles, and there were trends for additional improvements with each additional cycle (Box 2).

At baseline, the only significant differences in screening were those between states and territories for first trimester BP checks (P = 0.04), BP checks at any stage of the pregnancy (P = 0.02) and diabetes screening (P = 0.002). These differences were not significant at the PHCs’ final audits (all P > 0.05).

There were also indications of sustained improvements in the provision of follow-up actions after CQI participation, but the sample sizes were too small for statistical analysis. Follow-up actions for high BP included repeated BP assessment (pre-26 weeks, 88.1%; post-26 weeks, 91.9%), urine tests (pre-26 weeks, 88.1%, post-26 weeks, 83.9%), referral (pre-26 weeks, 85.7% post-26 weeks, 94.3%) and antihypertensive medication (pre-26 weeks, 42.9%, post-26 weeks, 26.4%). Follow-up OGTTs were reported for most women who received an abnormal GCT result. Few women with an abnormal BMI, however, had a documented BMI management plan (Box 3).

Systems assessment data were available for 35 PHCs (46.1%); data were available for more than one time point for 21. The mean overall SAT score at the final cycle (7.36) was statistically significantly higher than at the first cycle (6.23; P = 0.009), but there were no significant differences in SAT subscale scores between the first and final cycles (data not shown). Higher average self-ratings of some organisational systems were associated with greater provision of metabolic screening (Box 4). For example, the average provision of first trimester BP screening was 3.7 percentage points higher for each additional point scored on the SAT information systems and decision support domain. Diabetes screening was associated with higher overall self-ratings, as well as with higher ratings of self-management support systems, and of organisational influence and integration.

In addition, there was a statistically significant association between a one-point increase from first to final assessment in information systems and decision support scores and an increase of 5.7 percentage points in the proportion of women receiving diabetes screening between the first and final audits (β = 5.7; 95% CI, 0.6–10.9; P = 0.03). However, no other significant associations between changes in SAT scores and screening were detected (data not shown).

Discussion

This large longitudinal study of PHCs found substantial improvements in routine metabolic screening in pregnancy associated with participation in a CQI initiative. Improvements were sustained over multiple cycles, with evidence for additional improvements with each consecutive CQI cycle. Initiation of follow-up actions also improved after CQI participation. Higher self-ratings of some organisational systems were significantly associated with greater metabolic screening.

Screening at baseline was incomplete for all the metabolic risk factors investigated, consistent with reports from other Indigenous communities.17 It is unclear whether metabolic screening coverage in other maternity care settings is incomplete, as this information is not reported in other routine perinatal data collections. However, improvements associated with CQI participation were observed with respect to BMI and BP assessment and screening for diabetes during pregnancy. Measurement of BMI early in pregnancy is important because maternal and neonatal morbidity increases with maternal BMI,3 and the recommended gestational weight gain depends on the BMI category.1 Measurement of BMI may be influenced by both the mothers’ and health professionals’ understanding of the importance of healthy gestational weight gain and awareness of weight gain guidelines, and by the confidence of health professionals that they can discuss weight with women without causing undue concern.18 It is encouraging that we encountered no instances of women who declined to be weighed. Similarly, first trimester BP assessment and universal second trimester GDM screening are also recommended in Australia, and these remain areas for improvement. It is important to explore potential barriers to GDM screening, both because the prevalence of diabetes during pregnancy is higher among Indigenous women than in non-Indigenous women4 and because of the importance of diabetes management during pregnancy.4

Pregnancy is an opportune time for health practitioners to discuss weight management with women.19 However, few women in this study with an abnormal BMI had a management plan, which may reflect suboptimal action taken, a lack of documentation of the actions taken, or both. Excess weight gain increases pregnancy risks, such as macrosomia, preterm birth and the need for caesarean delivery,1 as well as the long-term risk of obesity,6 making active management vital for the wellbeing of mother and child. Potential barriers to developing weight management plans include limited resources for referral, food security concerns, and inadequate staff time, especially in remote communities. Development of resources or programs for gestational weight management tailored to the needs of Indigenous women may assist.

Most women with an abnormal GCT result subsequently underwent a diagnostic OGTT. Recent controversy about diabetes screening20 may have created barriers to screening and follow-up. While large-scale implementation of the International Association of Diabetes in Pregnancy Study Group guidelines, starting in 2015,21 may partially resolve these problems, the number of women diagnosed with GDM will also increase,22 with potential resource implications for PHCs.

The positive associations between self-ratings of organisational systems and first trimester BP and diabetes screening in our study support targeting of organisational systems as a strategy for improving the provision of metabolic screening during pregnancy. However, further large-scale improvements in systems and processes that support health professionals in conducting metabolic screening and management are vital if the long-term consequences of these complications in pregnancy are to be reduced. We hope that our findings encourage further discussion about how pregnancy care for Indigenous women might be improved. All levels of the health system have roles to play, and systems-based research networks, such as the ABCD Partnership, are ideally placed to develop appropriate strategies.

Our study was limited by the fact that SAT data were available for only some PHCs (35 of 76, 46.1%), reducing the statistical power of our analysis to detect associations. Selection bias was also possible, as this study included only the One21seventy PHCs that volunteered their data for research (58.5% of the audits conducted overall). Our data may not be representative of PHCs not participating in the One21seventy initiative, but this extensive network includes a large population, and there are currently no other comparable data sources in Australia. Bias caused by the possibility that PHCs with lesser improvement would be less likely to remain in the CQI initiative is difficult to gauge, as commencement years varied and PHCs may have conducted maternal health audits in non-consecutive years. However, the generalisability of our results may have been enhanced by the fact that PHCs used the audit tool according to their needs, rather than as a research requirement. As we performed multiple statistical tests, there was a risk of finding significant associations by chance. This possibility was reduced by not undertaking statistical tests for follow-up actions, as the small numbers involved were inadequate for meaningful comparisons.

The CQI initiative continues, and further assessment of its effects on service delivery and health outcomes is planned as the sample size increases. Future directions include investigating the effects on service provision of the audit year, the year of commencement, and the duration of CQI participation. A cluster randomised controlled trial is an alternative study design that could be used to test hypotheses arising from the current findings.

Despite the limitations, our study has significant strengths that increase the generalisability of its findings. Most previous CQI research in pregnancy care has been hospital-based, implemented in a single service, not focused on metabolic screening, or not conducted in Australia.23–25 Our research applied a unique system-wide participatory approach to assess systemic issues commonly affecting provision of care.14 It used a detailed, longitudinal dataset to investigate long-term sustainability, and included many PHCs across several settings.

Our study shows the potential of a CQI initiative supported by a systems-based research network to improve the provision of recommended pregnancy care at PHCs attended by Indigenous women. These findings are encouraging, and suggest a successful approach for achieving further improvement in pregnancy care provision.

Box 1 –
Characteristics of the 76 primary health care centres included in the study, and of the 2592 women whose records were audited

Characteristics of the primary health care centres

Governance structure

Government-operated

49 (64.5%)

Community-controlled

27 (35.5%)

Location

Remote

56 (73.7%)

Urban or regional

20 (26.3)

Service population size

≥ 1000 people

39 (51.3%)

< 1000 people

37 (48.7%)

State or territory

Northern Territory

28 (36.8%)

Queensland

27 (35.5%)

Western Australia

11 (14.5%)

New South Wales

6 (7.9%)

South Australia

4 (5.3%)

Characteristics of the women

Indigenous status∗

2141 (87.9%)

Aboriginal

2028 (83.3%)

Torres Strait Islander

57 (2.3%)

Aboriginal and Torres Strait Islander

56 (2.3%)

Age†

Median, years

24.4 (IQR, 20.6–29.6)

< 20 years

545 (21.1%)

20–34 years

1807 (69.9%)

≥ 35 years

233 (9.0%)

First attendance for pregnancy care occurred before 13 weeks’ gestation‡

1321 (51.0%)

Median number of pregnancy care visits

7 (IQR, 5–10)

IQR = interquartile range. ∗n = 2435 (data missing for 157 women). †n = 2585 (data missing for 7 women). ‡n = 2591 (data missing for 1 woman).

Box 2 –
Documented metabolic screening during pregnancy after completion of each continuous quality improvement (CQI) cycle, and associations between metabolic screening and primary health care centre (PHC) participation in each CQI cycle

Metabolic screening

CQI cycle

P (for trend)

076 PHCs

150 PHCs

228 PHCs

38 PHCs

46 PHCs

Weight measured in first trimester (1321 women)

440/562 (78.3%)

344/418 (82.3%)

153/202 (75.7%)

49/65 (75.4%)

56/74 (75.7%)

Odds ratio (95% CI)

1.0

1.4 (0.9–2.0) P = 0.10

1.0 (0.6–1.6) P = 0.89

1.2 (0.6–2.4) P = 0.59

1.4 (0.7–2.8) P = 0.34

0.38

BMI calculated in first trimester (1321 women)

132/562 (23.5%)

126/418 (30.1%)

63/202 (31.2%)

25/65 (38.5%)

31/74 (41.9%)

Odds ratio (95% CI)

1.0

2.4 (1.6–3.5) P < 0.001

3.4 (2.0–5.6) P < 0.001

5.1 (2.4–10.7) P < 0.001

9.4 (4.6–19.4) P < 0.001

< 0.001

Blood pressure check in first trimester (1321 women)

485/562 (86.3%)

370/418 (88.5%)

180/202 (89.1%)

56/65 (86.2%)

59/74 (79.7%)

Odds ratio (95% CI)

1.0

1.3 (0.8–1.9) P = 0.27

1.5 (0.9–2.7) P = 0.15

1.6 (0.7–3.7) P = 0.24

1.1 (0.5–2.3) P = 0.78

0.51

Blood pressure check at any point during the pregnancy (2592 women)

1123/1201 (93.5%)

745/758 (98.3%)

383/388 (98.7%)

131/135 (97.0%)

110/110 (100.0%)

Odds ratio (95% CI)

1.0

3.7 (1.9–7.3) P < 0.001

7.0 (2.5–19.4) P < 0.001

2.0 (0.6–6.5) P = 0.25

—

< 0.001

Diabetes screening (2541 women)∗

669/1192 (56.1%)

469/736 (63.7%)

234/380 (61.6%)

86/135 (63.7%)

74/98 (75.5%)

Odds ratio (95% CI)

1.0

1.3 (1.0–1.6) P = 0.04

1.2 (0.9–1.7) P = 0.15

1.7 (1.1–2.6) P = 0.02

3.4 (1.9–5.9) P < 0.001

< 0.001

BMI = body mass index. ∗In 2010, the audit tool was refined to include “not applicable” if women had already been diagnosed with diabetes, or were offered but declined BMI or blood pressure assessment or diabetes screening. Since 2010, 26 women were recorded as having pre-existing diabetes, and 25 women declined diabetes screening. This reduced the denominator for diabetes screening to 2541. There were no recorded instances of women declining BMI or blood pressure checks.

Box 3 –
Recorded metabolic abnormalities during pregnancy and subsequent follow-up after each continuous quality improvement (CQI) cycle

Metabolic risk factors and follow-up

CQI cycle

0

1

2

3

4

76 PHCs

50 PHCs

28 PHCs

8 PHCs

6 PHCs

Abnormal BMI in first trimester (377 women)

39/132 (29.6%)

34/126 (27.0%)

17/63 (27.0%)

5/25 (20.0%)

8/31 (25.8%)

BMI management plan (103 women)

6/39 (15.4%)

10/34 (29.4%)

6/17 (35.3%)

4/5 (80.0%)

4/8 (50.0%)

High blood pressure in first trimester (1150 women)

11/485 (2.3%)

12/370 (3.2%)

5/180 (2.8%)

1/56 (1.8%)

0/59

Blood pressure follow-up < 26 weeks (73 women)

13/32 (40.6%)

17/27 (63.0%)

7/9 (77.8%)

2/2 (100.0%)

3/3 (100.0%)

High blood pressure at any time during pregnancy (2492 women)

72/1123 (6.4%)

51/745 (6.8%)

25/383 (6.5%)

2/131 (1.5%)

8/110 (7.3%)

Blood pressure follow-up ≥ 26 weeks (110 women)

34/49 (69.4%)

30/35 (85.7%)

17/20 (85.0%)

no cases

6/6 (100.0%)

Abnormal GCT result (1530 women)

120/667 (18.0%)

92/469 (19.6%)

41/234 (17.5%)

15/86 (17.4%)

9/74 (12.2%)

Follow-up OGTT (277 women)

104/120 (86.7%)

81/92 (88.0%)

40/41 (97.6%)

14/15 (93.3%)

7/9 (77.8%)

PHC = primary health care centre; BMI = body mass index; GCT = glucose challenge test; OGTT = oral glucose tolerance test.

Box 4 –
Associations between the average proportions of women undergoing metabolic screening and average Systems Assessment Tool scores (across all cycles) for 35 primary health care centres (β-coefficient, 95% CI)

Overall score

Delivery system design

Information systems and decision support

Self-management support

External links

Organisational influence and integration

BMI calculated in first trimester

4.2 (−3.5 to 11.9)

2.7 (−4.8 to 10.2)

5.5 (−1.3 to 12.2)

3.5 (−1.6 to 8.6)

1.9 (−4.5 to 8.4)

1.2 (−5.1 to 7.4)

Blood pressure check in first trimester

2.6 (−0.6 to 5.8)

1.9 (−1.3 to 5.0)

3.7∗ (0.9 to 6.4)

1.5 (−0.6 to 3.7)

−0.6 (−3.4 to 2.1)

2.5 (−0.0 to 5.1)

Blood pressure check at any point during pregnancy

0.9 (−0.9 to 2.6)

0.5 (−1.2 to 2.2)

1.3 (−0.2 to 2.9)

0.3 (−0.9 to 1.5)

0.3 (−1.2 to 1.8)

0.7 (−0.8 to 2.1)

Diabetes screening

5.3∗ (0.6 to 10.1)

4.6 (−0.1 to 9.3)

3.8 (−0.6 to 8.2)

3.4∗ (0.2 to 6.7)

1.2 (−3.1 to 5.4)

4.9∗ (1.1 to 8.6)

BMI = body mass index. ∗P < 0.05.

The extra resource burden of in-hospital falls: a cost of falls study

In-hospital falls remain a major cause of harm in acute care hospitals; a multicentre study estimated that falls comprised about 40% of all reported patient incidents (11 766 of 28 998) in the British National Health System.1 They result in additional hospital costs because of their impact on hospital length of stay (LOS) and use of resources.2 Previous studies of the costs of falls have had methodological limitations — small samples from single hospitals, capture of fall events using single sources (resulting in measurement bias),3–5 modelled costs based on diagnosis-related group or per diem costs (known to be crude estimates of cost), or costing data more than 10 years old. Poor capture of fall events will result in inaccurate estimates of cost,6 while modelled costs are unlikely to reflect the true total cost attributable to the fall. Further, most studies have focused on falls resulting in serious injury,7,8 underestimating the total financial burden of in-hospital falls.

In Australia, only one study has examined the differences in the demand on resources by fallers and non-fallers in the acute hospital setting.9 This retrospective study was undertaken in a sample of 151 patients from a single hospital. Fallers were grouped by diagnosis-related group, and it was found that the LOS of patients who experienced a fall in hospital was up to 11 days longer than that of non-fallers (matched for age and sex). Costing analysis was undertaken for patients with complete costing data in the three most common diagnosis-related groups (39 pairs). Total hospital-related costs for fallers were reported to be double those for non-fallers, although no figures were cited. While this study provided insights into the increased consumption of resources caused by falls, the small sample consisted of a select group of patients from only one hospital. For this reason, data that can be generalised to the broader acute population in Australia are still needed.

Given the lack of comprehensive and contemporary data on the cost of falls, the aim of our study was to identify the economic burden associated with in-hospital falls in six Australian hospitals. The study had three main objectives:

  • to calculate the difference between the hospital LOS and costs of patients who experienced at least one in-hospital fall and of those who had not;

  • to calculate the difference between the hospital LOS and costs of patients who experienced at least one in-hospital fall injury and of those who had a non-injurious fall; and

  • to estimate the incremental change in hospital LOS and costs associated with each in-hospital fall or fall injury.

Methods

Study design

This multisite prospective study of the cost of falls was conducted as part of a larger falls prevention cluster randomised control trial, the 6-PACK project.10 A detailed description of the methods used in this study has been published elsewhere.6

Study population and setting

Our study included all patient admissions to 12 acute hospital wards in six public hospitals (metropolitan and regional teaching hospitals) in two Australian states (Victoria and New South Wales). The sample was restricted to wards randomised to the control group of the 6-PACK trial to minimise confounding due to the effects of the 6-PACK program. Participating wards included four general medical, two general surgical, one general medical short-stay, four specialist medical and one specialist surgical wards. All wards continued their standard care falls prevention practices during the study period.

Data collection and data sources

Data were prospectively collected in each hospital over a 15-month period during 2011–2013, including 3-month baseline and 12-month cluster randomised controlled trial study periods.

Fall events

An in-hospital fall was defined as “an event resulting in a person coming to rest inadvertently on the ground, floor, or other lower level”11 during their hospital stay. A fall injury was defined as any reported physical harm resulting from a fall; the injuries were classified as no injury, mild, moderate or major according to the definitions provided by Morse12 (Box 1).

Falls data were prospectively collected using a multimodal method to ensure maximal capture of falls events: (1) daily patient medical record audit; (2) daily verbal reports from the ward nurse unit manager; and (3) data extracts obtained from hospital incident reporting and administrative databases. Radiological investigation reports were reviewed to verify fractures. All recorded falls were reviewed and re-coded by a second independent assessor, and disagreements resolved by a third.

Patient hospital utilisation

Patient hospital utilisation was assessed on the basis of inpatient LOS and hospital episode costs. LOS was defined as the total number of hospital bed-days (calculated from the day of hospital admission to the day of discharge) and was extracted for all study participants from hospital administrative datasets. Patient hospital episode costs were extracted from hospital clinical costing systems. Hospitals with incomplete or poor-quality costing data (three of the six participating hospitals) were omitted from the costing analysis, but not from the LOS analysis; this involved 13 489 admissions, or 49.9% of the total number of admissions. Costs are reported in Australian dollars and were inflated to the base year 2013, based on the Australian Bureau of Statistics consumer price index for hospital services.13

Other hospital admission covariates

Data on patient demographics (age, sex) and admission characteristics (admission source, admission type, diagnoses) were obtained from hospital administrative datasets for all participants. Age was coded into four categories (< 55 years, 55–69 years, 70–84 years, ≥ 85 years). Admission type was coded into four categories (emergency v elective, and medical v surgical, based on diagnosis-related group classification). To account for comorbid illness on admission, comorbidities were generated with the Elixhauser comorbidity method.14 The assessment of cognitive impairment on or during a patient’s admission was based on International Classification of Diseases, 10th revision, Australian modification (ICD-10-AM) codes for dementia or delirium. A history of falls was defined as presenting with a fall or a history of falls coded as either the principal reason for admission or as an associated condition on admission.

Data linkage

Hospital administrative datasets were linked to data on fall events (linking variables: patient identifier, date of admission, date of event, ward). Data were then linked to patient hospital costing data (linking variables: patient identifier, date of admission). Three patients (0.02% of cohort) with missing costing data were excluded from the analysis of costs.

Statistical analysis

Descriptive and bivariate analyses of patient and admission characteristics and of hospital utilisation for each hospital admission were undertaken. Hospital LOS and costs were reported as means (with standard deviations) and medians (with interquartile ranges). If a patient was admitted to hospital several times during the study period, each admission was treated as a separate event. For patient admissions with an identified fall or fall injury, we analysed the average additional hospital LOS and costs with multivariate linear regression models (Box 2).

All analyses were adjusted for prespecified variables (age, sex, cognitive impairment6) and clustering by hospital (to account for in-hospital correlations). Additional admission covariates were included in the regression analysis if P < 0.25 in the bivariate analysis, or if they were clinically significant according to clinical opinion and literature. Standard errors were calculated using a bootstrap approach.15 Statistical significance was defined as P < 0.05 for all analyses. Data were analysed with Stata version 13 (StataCorp).

As hospital LOS and costing data were each positively skewed, cross-validation of the linear regression analyses was undertaken with generalised linear models that estimated the adjusted relative increase in LOS and costs for falls and fall injuries, using Poisson and gamma error distributions, respectively, and including a log-link function. In addition, multivariate linear regression analyses were undertaken, with log transformation of LOS and cost data. The smearing estimator developed by Duan and colleagues16 was used to retransform covariates from the log-scale back to the original scale (Australian dollars).

Sensitivity analysis

Sensitivity analyses were undertaken that separately compared the data of non-injured fallers with those of non-fallers, and of injured fallers with those of non-fallers. To examine the robustness of the cost of fall estimates, sensitivity analyses were undertaken that individually removed each of the hospitals to determine their influence on hospital costs and LOS, or that excluded patients who were deemed by visual inspection to be extreme statistical outliers (costs or LOS).

Ethics approval

This study received multicentre ethics approval from the Monash University Human Research Ethics Committee (project number CF11/0229–2011000072). Ethics and research governance approval was also obtained from local ethics committees at all participating hospitals.

Results

Our study included 21 673 unique patients and 27 026 patient hospital admissions (Box 3). We found that 966 hospital admissions (3.6%) involved at least one fall, and 313 (1.2%) at least one fall injury, a total of 1330 falls and 418 fall injuries. A summary of the numbers and types of fall events are summarised by hospital in Appendix 1.

Data for hospital LOS and costs for the total cohort and by group are summarised in Box 4. The total hospital costs of fallers in this dataset were $9.8 million, with $6.4 million attributable to non-injured fallers and $3.4 million to injured fallers. After adjustment for age, sex, cognitive impairment, admission type, comorbidity, history of falls on admission and clustering by hospital, the mean LOS for fallers was 8 days longer (95% CI, 5.8–10.4; P < 0.001) than for non-fallers, and on average they incurred $6669 more in hospital costs (95% CI, $3888–$9450; P < 0.001) (model 1a, Box 5). Each additional fall was associated with a longer LOS and additional hospital costs; the LOS for patients who experienced three or more falls was estimated as being 23 days longer (95% CI, 10.7–35.4; P = 0.003) than for non-fallers, and they incurred more than $21 000 in additional hospital costs (95% CI, $3035–$39 355; P < 0.001) (model 1b, Box 6).

Within the cohort of fallers, the mean LOS for an injured faller was 4 days longer (95% CI, 1.8–6.6; P = 0.001) than for a faller without injury. Consistent with our other findings, mean hospital costs were also higher (by $4727; 95% CI, −$568 to $10 022; P = 0.08), but the difference was not statistically significant (model 2a, Box 5). Each additional fall injury was associated with increased LOS and additional hospital costs (model 2b, Box 7); patients who experienced three or more in-hospital fall injuries were estimated to have a mean increase in LOS of 9 days (95% CI, 2.8–15.1; P = 0.004) compared with a faller without injury, and incurred more than $7000 in extra hospital costs (95% CI, −$3126 to $17 636; P = 0.171) (Box 7). There were no statistically significant differences in hospital LOS or costs associated with the severity of a fall-related injury (189 hospital admissions with mild injury, 89 with moderate injury, 35 with severe injury; model 2c). Results from models 1b, 2b and 2c are summarised in Appendix 2.

The cross-validation analyses of the linear regression using generalised linear models and log transformation of LOS and costs (Appendix 3) did not alter our conclusions.

Sensitivity analyses

Fallers who did not sustain injuries were estimated to have a mean increase in LOS of 7 days (95% CI, 5.1–8.7; P < 0.001) compared with non-fallers, and incurred mean additional hospital costs of $5395 (95% CI, $3788–$7002, P < 0.001). Injured fallers were estimated to have a mean increase of LOS of 11 days (95% CI, 5.1–8.7; P < 0.001) compared with non-fallers, and incurred mean additional hospital costs of $9917 (95% CI, $3273–$16 561; P = 0.003). Additional sensitivity analyses were undertaken to examine the robustness of study estimates by individually excluding each hospital from the analysis, and by excluding 78 patient admissions that appeared to be outliers with respect to hospital LOS or costs. There were no appreciable differences in the excess LOS or costs calculated by these analyses (results available from authors on request).

Discussion

This study found that in-hospital falls remain highly prevalent, with 3.6% of all patient admissions resulting in at least one fall, a third of which caused a fall injury. They are a significant burden on hospital resources because of the resulting increases in hospital LOS and costs, with patients who experience an in-hospital fall having nearly twice the LOS and costs of non-fallers. Our study shows that more than half of the additional costs associated with a fall injury can be attributed to the fall itself, not the injury.

The increase in resource burden associated with an in-hospital fall, whether the patient sustains an injury or not, may be caused by changes in the patient’s care pathway and discharge planning. Previous studies have found that a fall (regardless of injury) will affect the patient’s confidence and independence,17 and therefore influences their rate of recovery and plan to leave hospital. Best practice guidelines recommend that patients who have a fall be provided with strategies that minimise the risk of subsequent falls and an assessment of safety and readiness for discharge home.18,19 As a result, delivery of guideline-based care is likely to influence the overall hospital LOS, regardless of injury, and thus their use of hospital resources.

However, as our study was observational, it is possible that a fall might be the consequence of a patient’s longer hospital stay rather than its cause. Patients at risk of falling in the acute hospital setting are typically acutely unwell, often have multiple comorbidities, and take several medications. A fall may therefore reflect deterioration in an individual’s health and function rather than cause it. Further exploration of temporal trends in the occurrence of falls and the care pathway of patients following a fall event are warranted.

Some limitations should be considered when interpreting our findings. While we adjusted our analyses for potential confounding factors, unmeasured characteristics may have influenced hospital cost and LOS outcomes. These include differences in patient management across wards, severity of illness and acuity of care. There are also limitations associated with analysis of routinely collected hospital data for the assessment of health conditions,20 which may have resulted in the undercoding of confounding factors. However, the coding quality of ICD-10-AM in Australia has been found to be good to excellent for many diagnostic codes and comorbidities.21

The use of hospital costing data also poses challenges. While analysis of clinical costing data is a powerful research tool and aims to preserve information about variability in individual patient resource use,22 clinical costing standards are relatively new for Australian public hospitals. We observed some variability in the completeness and quality of the available costing data, and hospitals with incomplete or poor-quality costing data were removed from our costing analysis, resulting in a sample that included about half of the total study cohort. Finally, the results from our study only incorporated costs of hospitalisation from the acute hospital perspective, potentially providing a more conservative estimate of the overall resource burden.

Fall rates in the acute hospital setting remain unacceptably high and are clearly associated with longer hospital patient stays and higher hospital costs. The resource burden of in-hospital falls for the Australian hospital system is considerable. Our findings highlight the fact that falls prevention programs in the acute hospital setting need to focus not only on the minimisation of harm resulting from falls, but also on the prevention of all falls. In the absence of evidence from randomised control trials that supports the effectiveness of any single falls prevention strategy in the acute hospital setting,23 the challenge remains to develop innovative ways to prevent falls in hospital and to reduce the additional resource burden associated with these events. Our findings have important financial implications for hospitals in light of an ageing population and the growth in the burden of disease, and the complexity of patients within a health care system facing major cost constraints.

Box 1 –
Fall injury classification, according to Morse12

  • No injury: No physical damage (observed or documented) as a result of the fall
  • Mild injury: An injury (such as a bruise, swelling, abrasion, laceration or skin tear) that does not require medical treatment other than simple analgesia, such as paracetamol
  • Moderate fall injury: Dislocation, sprain and/or an injury that requires medical or surgical treatment
  • Major fall injury: Any fracture or head injury (open or closed), including subdural haematoma

Box 2 –
Linear regression models for analysis of additional hospital length of stay (LOS) and costs associated with a fall or fall-related injury

Model

Definition

1a

Additional hospital costs and LOS of patients who experience at least one in-hospital fall (fallers), compared with those who do not (non-fallers)

1b

Additional hospital costs and LOS of each additional in-hospital fall (1, 2, ≥ 3 falls) compared with non-fallers

2a

Additional hospital costs and LOS of patients who experience at least one in-hospital fall injury (injured fallers), compared with those who fell at least once but were not injured (non-injured fallers)

2b

Additional hospital costs and LOS of each additional in-hospital fall injury (1, 2, ≥ 3 injuries) compared with non-injured fallers

2c

Incremental hospital costs and LOS associated with the type of fall injury (based on the injury classification: mild, moderate and major fall injuries) compared with non-injured fallers

Box 3 –
Characteristics of the study cohort

Characteristic

All hospital admissions (n = 27 026)

Hospital admissions by faller status

Hospital admissions by injury status

Faller (n = 966)

Non-faller (n = 26 060)

P

Injured faller (n = 313)

Non-injured faller (n = 653)

P

Age

< 0.001

0.064

< 55 years

8332 (30.8%)

120 (12.4%)

8212 (31.5%)

32 (10.2%)

88 (13.5%)

55–69 years

6626 (24.5%)

188 (19.4%)

6438 (24.7%)

51 (16.3%)

137 (21.0%)

70–84 years

8730 (32.3%)

451 (46.7%)

8279 (31.8%)

152 (48.6%)

299 (45.8%)

≥ 85 years

3338 (12.4%)

207 (21.4%)

3131 (12.0%)

78 (24.9%)

129 (19.8%)

Sex (female)

12 997 (48.1%)

400 (41.4%)

12 597 (48.3%)

< 0.001

112 (35.8%)

288 (44.1%)

0.055

Admission type

< 0.001

0.338

Medical non-emergency

2421 (9.0%)

105 (10.9%)

2316 (8.9%)

34 (10.9%)

71 (10.9%)

Medical emergency

16 232 (60.1%)

637 (65.9%)

15 595 (59.8%)

207 (66.1%)

430 (65.8%)

Surgical non-emergency

4585 (17.0%)

122 (12.6%)

4501 (17.3%)

19 (6.1%)

65 (10.0%)

Surgical emergency

3355 (12.4%)

84 (8.7%)

3233 (12.4%)

45 (14.4%)

77 (11.8%)

Not recorded

433 (1.6%)

18 (1.9%)

415 (1.6%)

8 (2.6%)

10 (1.5%)

Admitted from nursing home

166 (0.6%)

13 (1.3)

153 (0.6%)

0.001

3 (1.0%)

10 (1.5%)

0.267

Reason for hospital admission

Injuries

3852 (14.3%)

114 (11.8%)

3738 (14.3%)

< 0.001

37 (11.8%)

77 (11.8%)

0.602

Digestive system diseases

3512 (13.0%)

71 (7.3%)

3441 (13.2%)

0.042

31 (9.9%)

40 (6.1%)

0.130

Circulatory system diseases

3150 (11.7%)

115 (11.9%)

3035 (11.6%)

0.907

25 (8.0%)

90 (13.8%)

0.008

Respiratory system diseases

3051 (11.3%)

107 (11.1%)

2944 (11.3%)

0.706

36 (11.5%)

71 (10.9%)

0.896

Cancer

3029 (11.2%)

152 (15.7%)

2877 (11.0%)

< 0.001

49 (15.7%)

103 (15.8%)

0.533

Genitourinary system diseases

1867 (6.9%)

48 (5.0%)

1819 (7.0%)

0.535

19 (6.1%)

29 (4.4%)

0.062

Musculoskeletal and connective tissues disease

1309 (4.8%)

41 (4.2%)

1268 (4.9%)

0.027

11 (3.5%)

30 (4.6%)

0.338

Endocrine, nutritional, metabolic diseases

989 (3.7%)

57 (5.9%)

932 (3.6%)

0.010

20 (6.4%)

37 (5.7%)

0.440

Infectious and parasitic diseases

978 (3.6%)

40 (4.1%)

938 (3.6%)

0.755

15 (4.8%)

25 (3.8%)

0.775

Mental and behavioural disorders

536 (2.0%)

59 (6.1%)

477 (1.8%)

< 0.001

17 (5.4%)

42 (6.4%)

0.587

Other

4753 (17.6%)

162 (16.8%)

4591 (17.6%)

0.584

53 (16.9%)

109 (16.7%)

0.782

Presence of cognitive impairment during admission*

1882 (7.0%)

270 (28.0%)

1612 (6.2%)

< 0.001

93 (29.7%)

177 (27.1%)

0.061

Total number of comorbidities on admission, mean (SD)†

1.8 (2.7)

2.5 (1.5)

1.5 (1.8)

< 0.001

2.7 (1.8)

2.4 (1.8)

0.532

History of falls on admission‡

2042 (7.6%)

133 (13.8%)

1961 (7.5%)

0.001

53 (16.9%)

80 (12.3%)

0.008

∗ICD-10-AM codes for delirium and dementia: F050, F051, F058, F059, F104, F106, F114, F124, F134, F144, F154, F164, F174, F184, F194, F430, F00-F03, G30, G311, G309. †Elixhauser comorbidity method.14 ‡ICD-10-AM codes for history of falls: W00, W01-10, W13-15 W17-19.

Box 4 –
Hospital length of stay and hospital costs for patient hospital admissions

Hospital length of stay

All hospital admissions (n = 27 026)

Hospital admissions with a fall (n = 966)

Hospital admissions without a fall (n = 26 060)

Hospital admissions with a fall (n = 966)

Admissions without a fall injury (n = 653)

Admissions with a fall injury (n = 313)

Mean hospital length of stay, days (SD)

7.9 (8.5)

19.5 (17.6)

18.0 (15.0)

22.5 (21.9)

Median hospital length of stay, days (IQR)

5 (3–9)

14 (9–24)

14 (8–23)

17 (9–27)

Hospital costs

All hospital admissions (n = 13 489)

Hospital admissions with a fall (n = 533)

Hospital admissions without a fall (n = 12 956)

Hospital admissions with a fall (n = 533)

Admissions without a fall injury (n = 376)

Admissions with a fall injury (n = 157)

Mean hospital costs, $ (SD)

9368 (12 572)

19 289 (21 712)

17 897 (17 317)

22 623 (29 511)

Median hospital costs, $ (IQR)

6038 (3658–10 585)

12 833 (8314–21 261)

12 821 (8440–20 904)

13 563 (7850–21 500)

IQR = interquartile range.

Box 5 –
Adjusted increased hospital use by patients with an in-hospital fall or fall injury (multivariate linear regression models)∗

Mean hospital length of stay, days (95% CI)

P

Mean hospital costs, $ (95% CI)

P

Faller (model 1a)

8.1 (5.8 to 10.4)

< 0.001

6669 (3888 to 9450)

< 0.001

Sex (female)

0.4 (0.2 to 0.6)

566 (41 to 1092)

0.035

Age

< 55 years

1.0

< 0.001

1.0

55–69 years

1.1 (0.6 to 1.6)

< 0.001

839 (−1575 to 3253)

0.496

70–84 years

1.6 (0.7 to 2.4)

< 0.001

1,698 (−856 to 4251)

0.193

≥ 85 years

2.0 (0.9 to 3.0)

< 0.001

795 (−1353 to 2944)

0.468

Cognitive impairment

4.8 (3.4 to 6.2)

< 0.001

5229 (943 to 9515)

0.017

Admission type

Medical non-emergency

1.0

1.0

Medical emergency

0.9 (−0.3 to 2.2)

0.146

906 (−524 to 2337)

0.214

Surgical non-emergency

1.7 (0.2 to 3.2)

0.023

7,330 (3730 to 10 930)

< 0.001

Surgical emergency

6.1 (3.9 to 8.2)

< 0.001

12 407 (1487 to 23 327)

0.026

Number of comorbidities†

2.1 (1.5 to 2.6)

< 0.001

2605 (1564 to 3647)

< 0.001

Admitted from nursing home

−0.3 (−2.7 to 2.2)

0.831

4549 (−2697 to 11 794)

0.219

History of falls on admission

0.5 (−1.1 to 2.0)

0.567

−549 (−2490 to 1393)

0.580

Injured faller (model 2a)

4.2 (1.8 to 6.6)

0.001

4727 (−568 to 10 022)

0.080

Sex (female)

1.0 (−0.8 to 2.8)

0.278

519 (−1580 to 2618)

0.628

Age

< 55 years

1.0

0.784

1.0

55–69 years

−0.4 (−3.0 to 2.2)

0.556

−7095 (−20 182 to 5992)

0.288

70–84 years

−0.9 (−3.9 to 2.1)

0.111

−5772 (−17 208 to 5665)

0.323

≥ 85 years

−1.3 (−2.9 to 0.3)

<0.001

−8436 (−20 759 to 3887)

0.180

Cognitive impairment

5.3 (2.6 to 8.0)

6865 (1575 to 12 155)

0.011

Admission type

Medical non-emergency

1.0

1.0

Medical emergency

−0.7 (−3.7 to 2.4)

0.664

−973 (−3103 to 1157)

0.371

Surgical non-emergency

9.7 (2.9 to 16.5)

0.005

11 272 (2769 to 19 774)

0.009

Surgical emergency

10.3 (5.2 to 15.2)

< 0.001

19 706 (1530 to 37 881)

0.034

Number of comorbidities†

2.7 (1.3 to 4.2)

< 0.001

3065 (1366 to 4763)

< 0.001

Admitted from nursing home

−4.0 (−13.2 to 5.3)

0.404

6953 (−14 912 to 28 819)

0.533

History of falls on admission

−0.4 (−2.1 to 1.3)

0.659

−3778 (−7787 to 231)

0.065

∗The intraclass correlation coefficient was 0.002 for the number of falls (95% CI, 0.000–0.005) and 0.001 for number of fall injuries (95% CI, 0.000–0.003). †Elixhauser comorbidity method.14

Box 6 –
Adjusted increases in hospital length of stay (LOS) and costs associated with each additional fall (total study cohort)

Data expressed as means ± standard errors.

Box 7 –
Adjusted increases in hospital length of stay (LOS) and costs associated with each additional fall injury (faller cohort only)

Data expressed as means ± standard errors.

[Editorial] Canada’s healthy future?

Justin Trudeau, Canada’s new Prime Minister-designate, laid out several policies in his Liberal Party’s manifesto in the run-up to the Oct 19 national election, which will see the return of the Trudeau family to 24 Sussex Drive, Ottawa. There are promises to re-engage with First Nation Canadians, abandoned from health service planning by the Stephen Harper stewardship of the past decade; appoint a Chief Science Officer within government (to help the nation re-connect with a community often viewed by the previous administration with mistrust and suspicion); legalise cannabis; commit to stronger action on climate change; and increase funding for the devolved provincial and territory health systems to offer improved services, notably in the areas of elderly care and mental health.

Patients, hospitals to carry the cost of MBS Review

Patients and hospitals could be left carrying the tab if the Federal Government pushes ahead with plans to fast-track the removal of items from the Medicare Benefits Schedule while leaving the approval of new procedures and services languishing in the slow lane, the AMA has warned.

The AMA has told the Government its current controversial approach to the MBS Review not only puts the support of the medical profession at risk, but could result in patients losing Medicare rebates for services they need and instead winding up in public hospital.

Under Government plans, MBS Review Taskforce recommendations to scrap or modify existing Medicare items will go straight to Health Minister Sussan Ley for approval, while adding new services and procedures will be put in the hands of the much slower moving Medical Services Advisory Committee process.

AMA President Professor Brian Owler said this two-tiered approach would leave the MBS disjointed.

“The process outlined by the Taskforce will lead to a fragmented MBS because items will be removed and minor amendments will be made quickly, while any new items to reflect modern practice would languish in the slow-moving Medical Services Advisory Committee pipeline without being added,” Professor Owler said.

Instead, the AMA has recommended there be a single, comprehensive update process in which the Review’s 35 proposed clinical committees and working groups would make recommendations on both the removal and modification of existing items, and the inclusion of new items.

Related: It is not about savings, honest: Minister reassures AMA on MBS review

The peak medical group admitted this would be a lengthier process than that suggested by the Taskforce, and would involve a broader remit for the clinical committees than is currently envisaged.

But Professor Owler said it would be an efficient and transparent process that would produce “a modern MBS that reflects high quality, contemporary medical practice”.

“It is vitally important that the process is rigorous, and ensures that the initial set of findings is tested sufficiently with the relevant medical groups to rule out unintended consequences,” he said. “The AMA is proposing a process that would be more efficient and transparent, and which would be more likely to be support the clinical services that patients need.”

In its submission to the MBS Review Taskforce on its recently-released Consultation Paper, the AMA bemoaned recent attempts by Ms Ley and Taskforce Chair Professor Bruce Robinson to frame the process in terms of cost-cutting by claiming that 97 per cent of MBS items have never been assessed for their clinical effectiveness, and that 30 per cent of health spending is wasted.

“The Government does not need to justify the Review on such spurious grounds,” the AMA submission said. “A review of the MBS has the support of the medical profession because the MBS is in desperate need of updating.”

The AMA said the Review should be undertaken free from preconceptions or savings targets, reiterating that a process driven by arbitrary cost-cutting, or which diverts money from health into general revenue, would not be supported by the medical profession.

It said that for the Review to have the profession’s full confidence, it must emphasise patient care, deliver a schedule that reflects modern medical practice, and which supports the informed choices of patients.

View the AMA’s submission to the MBS Review Taskforce on its Consultation Paper.

Adrian Rollins

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National key performance indicators for Aboriginal and Torres Strait Islander primary health care: results from December 2014

This is the third national report on the national Key Performance Indicators (nKPIs) data collection. It captures data from more than 230 primary health care organisations that receive funding from the Australian Government Department of Health to provide services primarily to Aboriginal and Torres Strait Islander people. It presents data for 21 ‘process-of-care’ and ‘health outcome’ indicators, which focus on maternal and child health, preventative health and chronic disease management. The report shows improvements against almost all of the indicators.