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    Public reporting of clinician-level data

    Rachel Canaway, Marie M Bismark, David Dunt and Margaret A Kelaher
    Med J Aust 2017; 207 (6): . || doi: 10.5694/mja16.01402
    Published online: 18 September 2017

    There is much debate about public disclosure of individual doctors’ performance to increase hospital quality and safety, but research is lacking

    In 2016, media coverage of a cluster of preventable deaths of babies born at a Victorian health service1 shone a spotlight in Australia on the role of public reporting of hospital performance data in assuring quality and safety. The subsequent Victorian government review2 suggested that the Victorian health system must develop a culture of candour with improved transparency at every level of the hospital system “through greater public reporting of outcomes data and support for a just culture in hospitals”.2 Other failures in hospital quality have similarly triggered inquiries and health system reform in Australia.3,4 For example, Queensland’s Bundaberg Hospital scandal in 2005 triggered changes to public reporting to further encourage cultures in hospitals to move away from the “name–shame–blame” approach.5

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      Road safety: serious injuries remain a major unsolved problem

      Ben Beck, Peter A Cameron, Mark C Fitzgerald, Rodney T Judson, Warwick Teague, Ronan A Lyons and Belinda J Gabbe
      Med J Aust 2017; 207 (6): . || doi: 10.5694/mja17.00015
      Published online: 11 September 2017

      Abstract

      Objective: To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury.

      Design, setting and participants: A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007–2015.

      Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type.

      Results: There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00; 95% CI, 0.99–1.01; P = 0.70), motorcyclists (IRR, 0.99; 95% CI, 0.97–1.01; P = 0.45) or pedestrians (IRR, 1.00; 95% CI, 0.97–1.02; P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08; 95% CI; 1.05–1.10; P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007–2015, although the cost per patient declined for all road user groups.

      Conclusions: As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.

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      • 1 Monash University, Melbourne, VIC
      • 2 Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC
      • 3 National Trauma Research Institute, Melbourne, VIC
      • 4 Private Medical Centre, Royal Melbourne Hospital, Melbourne, VIC
      • 5 Royal Children's Hospital, Melbourne
      • 6 Farr Institute, Swansea University, Swansea, Wales, United Kingdom


      Correspondence: ben.beck@monash.edu
      Acknowledgements: 

      The Victorian State Trauma Registry (VSTR) is funded by the Department of Health and Human Services, the State Government of Victoria, and the Transport Accident Commission. Ben Beck received salary support from the National Health and Medical Research Council (NHRMC) Australian Resuscitation Outcomes Consortium (Aus-ROC) Centre of Research Excellence (1029983). Peter Cameron was supported by an NHMRC Practitioner Fellowship (545926) and Belinda Gabbe by an NHMRC Career Development Fellowship (GNT1048731). Warwick Teague’s role as director of trauma services at the Royal Children’s Hospital, Melbourne, is supported by a grant from the Royal Children’s Hospital Foundation. We thank the Victorian State Trauma Outcome Registry and Monitoring (VSTORM) group for providing VSTR data. We also thank Sue McLellan for her assistance with the data, Pam Simpson for her statistical support, and David Attwood from the Transport Accident Commission for his suggestions and advice.

      Competing interests:

      No relevant disclosures.

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        Radiation therapy and early breast cancer: current controversies

        John Boyages
        Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.01020
        Published online: 4 September 2017

        Summary

         

        • Radiation therapy (RT) is an important component of breast cancer treatment.
        • RT reduces local recurrence and breast cancer mortality after breast conservation for all patients and for node-positive patients after a mastectomy.
        • Short courses of RT over 3–4 weeks are generally as effective as longer courses.
        • A patient subgroup where RT can be avoided after conservative surgery has not been consistently identified.
        • A radiation boost reduces the risk of a recurrence in the breast but may be omitted for older patients with good prognosis tumours with clear margins.
        • Axillary recurrences can take a long time to appear, with 35% occurring after 5 years.
        • Leaving disease untreated in regional nodes is associated with reduced survival.
        • Not all patients require radiation after neoadjuvant chemotherapy and a subsequent mastectomy.
        • Modern RT equipment and techniques will further improve survival rates.

         


        • Macquarie University, Sydney, NSW


        Correspondence: john.boyages@mq.edu.au
        Acknowledgements: 

        I thank Ellen Tailby for research assistance, Philippa Sutton for editing and managing earlier versions of the manuscript, and Sergio Duque and Lesley Baker for the volumetric modulated arc therapy plan of the patient shown in Box 5.

        Competing interests:

        No relevant disclosures.

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          Non-coeliac gluten or wheat sensitivity: emerging disease or misdiagnosis?

          Michael DE Potter, Marjorie M Walker and Nicholas J Talley
          Med J Aust 2017; 207 (5): . || doi: 10.5694/mja17.00332
          Published online: 4 September 2017

          Summary

           

          • Non-coeliac gluten or wheat sensitivity (NCG/WS) is a condition characterised by adverse gastrointestinal and/or extra-intestinal symptoms associated with the ingestion of gluten- or wheat-containing foods, in the absence of coeliac disease or wheat allergy.
          • Up to one in 100 people in Australia may have coeliac disease but many more report adverse gastrointestinal and/or extra-intestinal symptoms after eating wheat products.
          • In the absence of validated biomarkers, a diagnosis of NCG/WS can only be made by a double-blind, placebo-controlled, dietary crossover challenge with gluten, which is difficult to apply in clinical practice.
          • Of people self-reporting gluten or wheat sensitivity, only a small proportion (16%) will have reproducible symptoms after a blinded gluten challenge of gluten versus placebo in a crossover dietary trial and fulfil the current consensus criteria for a diagnosis of NCG/WS.
          • A wide range of symptoms are associated with NCG/WS, including gastrointestinal, neurological, psychiatric, rheumatological and dermatological complaints.
          • The pathogenesis of NCG/WS is not well understood, but the innate immune system has been implicated, and there is overlap with coeliac disease and the functional gastrointestinal disorders (irritable bowel syndrome and functional dyspepsia).
          • Identification of NCG/WS is important as gluten-free diets carry risks, are socially restricting and are costlier than regular diets.

           

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          • 1 University of Newcastle, Newcastle, NSW
          • 2 Medical Journal of Australia, Sydney, NSW


          Competing interests:

          Nicholas Talley is Editor-in-Chief of the Medical Journal of Australia.

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            Testing for type 2 diabetes in Indigenous Australians: guideline recommendations and current practice

            Christine L Paul, Paul Ishiguchi, Catherine A D'Este, Jonathan E Shaw, Rob W Sanson-Fisher, Kristy Forshaw, Alessandra Bisquera, Jennifer Robinson, Claudia Koller and Sandra J Eades
            Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.00769
            Published online: 4 September 2017

            Abstract

            Objectives: To determine the proportion of Aboriginal Controlled Community Health Service (ACCHS) patients tested according to three national diabetes testing guidelines; to investigate whether specific patient characteristics were associated with being tested.

            Design, setting and participants: Cross-sectional study of 20 978 adult Indigenous Australians not diagnosed with diabetes attending 18 ACCHSs across Australia. De-identified electronic whole service data for July 2010 – June 2013 were analysed.

            Main outcomes measures: Proportions of patients appropriately screened for diabetes according to three national guidelines for Indigenous Australians: National Health and Medical Research Council (at least once every 3 years for those aged 35 years or more); Royal Australian College of General Practitioners and Diabetes Australia (at least once every 3 years for those aged 18 years or more); National Aboriginal Community Controlled Health Organisation (annual testing of those aged 18 years or more at high risk of diabetes).

            Results: 74% (95% CI, 74–75%) of Indigenous adults and 77% (95% CI, 76–78%) of 10 760 patients aged 35 or more had been tested for diabetes at least once in the past 3 years. The proportions of patients tested varied between services (range: all adults, 16–90%; people aged 35 years or more, 23–92%). 18% (95% CI, 18–19%) of patients aged 18 or more were tested for diabetes annually (range, 0.1–43%). Patients were less likely to be tested if they were under 50 years of age, were transient rather than current patients of the ACCHS, or attended the service less frequently.

            Conclusions: Some services achieved high rates of 3-yearly testing of Indigenous Australians for diabetes, but recommended rates of annual testing were rarely attained. ACCHSs may need assistance to achieve desirable levels of testing.

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            • 1 University of Newcastle, Newcastle, NSW
            • 2 Priority Research Centre for Health Behaviour, University of Newcastle, Newcastle, NSW
            • 3 Hunter Medical Research Institute, Newcastle, NSW
            • 4 Baker IDI Heart and Diabetes Institute, Melbourne, VIC
            • 5 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT


            Correspondence: chris.paul@newcastle.edu.au
            Acknowledgements: 

            The authors gratefully acknowledge the generous support of the staff and patients from the following Aboriginal Community Controlled Health Services (in alphabetical order): Anyinginyi Health Aboriginal Corporation, Bega Garnbirringu Aboriginal Health Service, Danila Dilba Biluru Butji Binnilutum Health Service, Derbarl Yerrigan Health Service, Dhauwurd-Wurrung Elderly and Community Health Service, Kirrae Aboriginal Health Service, Mawarnkarra Health Service, Mildura Aboriginal Corporation, Mitwatj Health Aboriginal Corporation, Pika Wiya Health Service, Riverina Medical and Dental Aboriginal Corporation, South West Aboriginal Medical Service, Sunrise Health Service Aboriginal Corporation, Umoona Tjutagku Health Service, Winnunga Nimmityajah Aboriginal Health Service, Ampilatwatja Health Centre Aboriginal Corporation, Pius X Aboriginal Corporation, and Victorian Aboriginal Health Service.

            Competing interests:

            No relevant disclosures.

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              Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project

              William A Parsonage, Tanya Milburn, Sarah Ashover, Wade Skoien, Jaimi H Greenslade, Louise McCormack and Louise Cullen
              Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.01479
              Published online: 4 September 2017

              Abstract

              Objective: To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain.

              Design: Quasi-experimental design, with interrupted time series analysis for the period October 2013 – November 2015.

              Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland.

              Intervention: Implementation of the ADP by structured clinical re-design.

              Main outcome measures: Primary outcome: hospital LOS. Secondary outcomes: ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS).

              Results: Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74–0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72–0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3–78.5%) to 54.9% (95% CI, 44.7–67.6%; P < 0.01). The estimated release in financial capacity amounted to $2.3 million as the result of reduced ED LOS and $11.2 million through fewer hospital admissions.

              Conclusions: Implementing an evidence-based ADP for assessing patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.

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              • 1 Royal Brisbane and Women's Hospital, Brisbane, QLD
              • 2 Queensland University of Technology, Brisbane, QLD
              • 3 The University of Queensland, Brisbane, QLD


              Correspondence: w.parsonage@mac.com
              Acknowledgements: 

              The ACRE Project was funded by the Queensland Government Department of Health. We acknowledge the support of the Healthcare Improvement Unit, Queensland Department of Health. We thank the Queensland Research Linkage Group of the Department of Health for assistance with linking data from the emergency department and inpatient datasets. We also gratefully acknowledge the contributions of former project officers Jennifer Bilesky, Jo Sippel and Vandana Bettens in the early development of the project, and the staff of the participating hospitals.

              Competing interests:

              No relevant disclosures.

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              • 14. Fanaroff AC, Schulteis RD, Pieper KS, et al. Simplified predictive instrument to rule out acute coronary syndromes in a high-risk population. J Am Heart Assoc 2015; 4: e002351.
              • 15. Roffi M, Patrono C, Collet JP, et al. Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2016; 37: 267-315.
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                Statistical and clinical significance

                Ian A Scott
                Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.01148
                Published online: 4 September 2017

                In published research, a statistically significant result is often wrongly interpreted as representing a clinically important finding. In this article, we explore the meanings of statistical and clinical significance.


                • 1 Princess Alexandra Hospital, Brisbane, QLD
                • 2 University of Queensland, Brisbane, QLD


                Correspondence: ian.scott@health.qld.gov.au
                Competing interests:

                No relevant disclosures.

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                  Improving the safety of breast implants: implant-associated lymphoma

                  Ingrid Hopper, Susannah Ahern, John J McNeil, Anand K Deva, Elisabeth Elder, Colin Moore and Rodney Cooter
                  Med J Aust 2017; 207 (5): . || doi: 10.5694/mja17.00005
                  Published online: 28 August 2017

                  A likely causal link between breast implants and lymphoma highlights the importance of a prospective registry

                  Breast devices, including implants and tissue expanders, are classified as class III (high risk) medical devices by the Therapeutic Goods Administration, and are subject to the highest level of regulatory control. They have been associated with highly publicised health scares in the past, particularly, the Poly Implant Prothèse crisis.1 More recently, breast implants have again created national concern, with the Therapeutic Goods Administration confirming in late 2016 that there were 46 reports of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) in Australia, including three cases that resulted in death. This number has since increased to 53.2 Most breast implants are used in young women and in women who have had breast cancer, thus long term exposure to these devices can be anticipated. It is therefore imperative to identify serious adverse effects at the earliest opportunity. The Australian Breast Device Registry is ideally positioned to do this, but it requires sufficient resources and engagement to ensure that it remains fit for purpose.


                  • 1 Monash University, Melbourne, VIC
                  • 2 University of Melbourne, Melbourne, VIC
                  • 3 Macquarie University, Sydney, NSW
                  • 4 Integrated Specialist Healthcare, Sydney, NSW
                  • 5 Westmead Breast Cancer Institute, Sydney, NSW
                  • 6 Breast Surgeons of Australia and New Zealand, Sydney, NSW
                  • 7 Australasian College of Cosmetic Surgery, Sydney, NSW
                  • 8 Australasian Foundation for Plastic Surgery, Sydney, NSW


                  Correspondence: Ingrid.Hopper@monash.edu
                  Acknowledgements: 

                  The Department of Health provides funding for the Australian Breast Device Registry. Ingrid Hopper is supported by a National Health and Medical Research Council early career fellowship.

                  Competing interests:

                  No relevant disclosures.

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                  Online responses are no longer available. Please refer to our instructions for authors page for more information.

                    Coeliac disease: review of diagnosis and management

                    Marjorie M Walker, Jonas F Ludvigsson and David S Sanders
                    Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.00788
                    Published online: 21 August 2017

                    Summary

                     

                    • Coeliac disease is an immune-mediated systemic disease triggered by exposure to gluten, and manifested by small intestinal enteropathy and gastrointestinal and extra-intestinal symptoms. Recent guidelines recommend a concerted use of clear definitions of the disease.
                    • In Australia, the most recent estimated prevalence is 1.2% in adult men (1:86) and 1.9% in adult women (1:52). Active case finding is appropriate to diagnose coeliac disease in high risk groups. Diagnosis of coeliac disease is important to prevent nutritional deficiency and long term risk of gastrointestinal malignancy.
                    • The diagnosis of coeliac disease depends on clinico-pathological correlation: history, presence of antitransglutaminase antibodies, and characteristic histological features on duodenal biopsy (when the patient is on a gluten-containing diet). Human leucocyte antigen class II haplotypes DQ2 or DQ8 are found in nearly all patients with coeliac disease, but are highly prevalent in the general population at large (56% in Australia) and testing can only exclude coeliac disease for individuals with non-permissive haplotypes.
                    • Adhering to a gluten free diet allows duodenal mucosal healing and alleviates symptoms. Patients should be followed up with a yearly review of dietary adherence and a health check.
                    • Non-coeliac gluten or wheat protein sensitivity is a syndrome characterised by both gastrointestinal and extra-intestinal symptoms related to the ingestion of gluten and possibly other wheat proteins in people who do not have coeliac disease or wheat allergy recognised by diagnostic tests.

                     


                    • 1 University of Newcastle, Newcastle, NSW
                    • 2 Karolinksa Institutet, Stockholm, Sweden
                    • 3 Royal Hallamshire Hospital, Sheffield, United Kingdom


                    Competing interests:

                    No relevant disclosures.

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                      Opting for rural practice: the influence of medical student origin, intention and immersion experience

                      Denese Playford, Hanh Ngo, Surabhi Gupta and Ian B Puddey
                      Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.01322
                      Published online: 21 August 2017

                      Abstract

                      Objective: To compare the influence of rural background, rural intent at medical school entry, and Rural Clinical School (RCS) participation on the likelihood of later participation in rural practice.

                      Design: Analysis of linked data from the Medical School Outcomes Database Commencing Medical Students Questionnaire (CMSQ), routinely collected demographic information, and the Australian Health Practitioner Regulation Agency database on practice location.

                      Setting and participants: University of Western Australia medical students who completed the CMSQ during 2006–2010 and were practising medicine in 2016.

                      Main outcome measures: Medical practice in rural areas (ASGC-RAs 2–5) during postgraduate years 2–5.

                      Results: Full data were available for 508 eligible medical graduates. Rural background (OR, 3.91; 95% CI, 2.12–7.21; P < 0.001) and experience in an RCS (OR, 1.93; 95% CI, 1.05–3.54; P = 0.034) were significant predictors of rural practice in the multivariate analysis of all potential factors. When interactions between intention, origin, and RCS experience were included, RCS participation significantly increased the likelihood of graduates with an initial rural intention practising in a rural location (OR, 3.57; 95% CI, 1.25–10.2; P = 0.017). The effect of RCS participation was not significant if there was no pre-existing intention to practise rurally (OR, 1.38; 95% CI, 0.61–3.16; P = 0.44).

                      Conclusion: For students who entered medical school with the intention to later work in a rural location, RCS experience was the deciding factor for realising this intention. Background, intent and RCS participation should all be considered if medical schools are to increase the proportion of graduates working rurally.

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                      • 1 The Rural Clinical School of Western Australia, University of Western Australia, Perth, WA
                      • 2 University of Western Australia, Perth, WA


                      Correspondence: denese.playford@uwa.edu.au
                      Acknowledgements: 

                      We acknowledge the statistical advice of Sharon Evans, senior biostatistician, and the support of David Atkinson, head of the Rural Clinical School of Western Australia.

                      Competing interests:

                      No relevant disclosures.

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