The 2018 version of the Australian Atlas of Healthcare Variation was released on December 11. This is the third such annual atlas, which examines differences in healthcare use according to where people live within Australia and is produced by the Australian Commission on Safety and Quality in Health Care in partnership with the Australian Institute of Health and Welfare. This year it looks at healthcare use in four selected clinical areas: paediatric and neonatal health; cardiac tests; thyroid investigations and treatments; gastrointestinal investigations and treatment. Specific recommendations for improvements are made. There are interactive features available.
What the report found
The report highlights how much work there is to be done in ensuring best practice, better access and implementing the principles of Choosing Wisely. Some examples:
- In 2015, 42 – 60 percent of planned C-sections performed before 39 weeks did not have a medical or obstetric indication. The highest rates were in private hospitals.
- Antibiotic use in Australian children is three times higher than for children in Norway and the Netherlands.
- There is significant prescribing of proton pump inhibitor drugs to treat colic in infants despite the fact that there is no evidence they are effective and they increase the risk of gastroenteritis and pneumonia. These drugs are also used inappropriately for long periods by adults.
- Patterns of use for colonoscopy and gastroscopy suggest over-use in some areas and populations groups and under-use by others (Indigenous Australians, people living in outer regional and remote areas, and people living in low socio-economic status areas) due to limited access.
- There is evidence to suggest over-testing for thyroid functioning. Disease patterns do not explain the variations seen in neck ultrasounds and thyroidectomies.
- Variations in cardiac testing indicate both over-use in some areas and lack of ready access in others. There needs to be a clinical care standard on diagnosis, investigation and management of ischaemic heart disease.
A separate section of the atlas examines national patterns in medicines use over time (for 2013-14 and 2016-17) for four common groups of medicines: antipsychotics, opioids, antimicrobials and medications for attention deficit hyperactivity disorder (ADHD). A detailed publication showing variation at a local level will be available in 2019 for this work. The current report does include recommendations for the appropriate use of antipsychotic medicines in people aged 65 years and over.
Taken together these represent some key areas for reforms in health policy and financing and in ensuring best practice in clinical areas. The recommendations are summarised here:
- The need to reduce harm in the provision of healthcare (eg too many early, planned C-sections).
- The ability of well-informed consumers to be powerful agents for improving the appropriateness of care (eg over-prescribing of antibiotics).
- Disturbing patterns of inequity (eg despite higher rates of bowel cancer, poorer Australians have less access to colonoscopy).
- Markedly higher healthcare use in some areas with no clear clinical indication (eg rate of prescribing of medicines for ADHD in 75 times higher in the local area with the highest rates than in the local area with the lowest rate).
- System factors can influence the use of particular treatments (eg. prescribing of anti-depressants is high in Tasmania because availability of mental health services is limited).
- There is a need for regular public reporting, access to more complete and informative data, quality improvement strategies for the use of tests, and better information for consumers to allow informed decisionmaking.
While some variation in how health care is provided is desirable because of differences in health status of populations and individuals, variation that is unrelated to patients’ needs or preferences – termed unwarranted variation – raises questions about quality, equity and efficiency for healthcare services.
Atlases of healthcare variation are a valuable tool for improving equity of access to appropriate services, the health outcomes of populations, and the value derived from investment in healthcare and for reducing the potential harms and waste resulting from unnecessary or inappropriate prescriptions and procedures. They also provide information about the effectiveness of dissemination of best practice guidelines and of health literacy initiatives.
If Australia is to gain maximum benefit from the information provided in the annual Atlas of Healthcare Variations, then more research and more attention to the findings will be required. Determining if variation is unwarranted can be challenging, particularly without routine information on patient needs and treatment outcomes. More must be done to increase awareness of recommendations for clinical practice such as provided by the National Prescribing Service, Choosing Wisely, the MBS Review and through the development of clinical practice guidelines and clinical pathways. And systemic reforms are needed to address health inequities, which must be seen as a key goal in order to ensure the continued universality of the Australian healthcare system.
It is somewhat disturbing to see the sizeable time lag and levels of adherence in the adoption by medical practitioners of evidence-based recommendations. There is no data to suggest that Australian clinicians are any better than their international counterparts in this regard. The Atlas does show some changes in practice over time (there has been some improvement in the rate of antibiotic prescribing) but some issues, which have clearly been identified as problematic for some time, are headed in the wrong direction (planned, early C-sections being the classic example).
It is even more disturbing to see – in this report and elsewhere – a growing assumption that patients must be the ones to drive improvements in the appropriateness of care. Clinicians cannot cast this responsibility aside so easily; rather they must work in partnership with their patients (and the patients’ families and carers) to reach the best decisions together. Yes, that will take time and effort on both sides and governments must see such joint decision-making as an investment in best outcomes and provide appropriate financial rewards to encourage this.
Dr Lesley Russell is an adjunct associate professor in the Menzies Centre for Health Policy at the University of Sydney.