Hospital utilisation in Australia, 1993-2020, with a focus on use by people over 75 years of age: a review of AIHW data.

OBJECTIVES: To assess Australian hospital utilisation, 1993-2020, with a focus on use by people aged 75 years or more. DESIGN: Review of Australian Institute of Health and Welfare (AIHW) hospital utilisation data. SETTING, PARTICIPANTS: Tertiary data from all Australian public and private hospitals for the financial years 1993-94 to 2019-20. MAIN OUTCOME MEASURES: Numbers and population-based rates of hospital separations and bed utilisation (bed-days) (all and multiple day admissions) and mean hospital length of day (multiple day admissions), overall and by age group (under 65 years, 65-74 years, 75 years or more). RESULTS: Between 1993-94 and 2019-20, the Australian population grew by 44%; the number of people aged 75 years or more increased from 4.6% to 6.9% of the population. The annual number of hospital separations increased from 4.61 million to 11.33 million (146% increase); the annual hospital separation rate increased from 261 to 435 per 1000 people (66% increase), most markedly for people aged 75 years or more (from 745 to 1441 per 1000 people; 94% increase). Total bed utilisation increased from 21.0 million to 29.9 million bed-days (42% increase), but the bed utilisation rate did not change markedly (1993-94, 1192 bed-days per 1000 people; 2019-20, 1179 bed-days per 1000 people), primarily because the mean hospital length of stay for multiple day admissions declined from 6.6 days to 5.4 days; for people aged 75 years or more it declined from 12.2 to 7.1 days. However, declines in stay length have slowed markedly since 2017-18. Total bed utilisation was 16.8% lower than projected from 1993-94 rates, and was 37.3% lower for people aged 75 years or more. CONCLUSION: Hospital bed utilisation rates declined although admission rates increased during 1993-94 to 2019-20; the proportion of beds occupied by people aged 75 years or more increased slightly during this period. Containing hospital costs by limiting bed availability and reducing length of stay may no longer be a viable strategy.

In search of professional consensus in defining and reducing low-value care.

Care that confers no benefit or benefit that is disproportionately low compared with its cost is of low value and potentially wastes limited resources. It has been claimed that low-value care consumes at least 20% of health care resources in the United States - the comparable figure in Australia is unknown but there is emerging evidence of overuse of diagnostic tests and therapeutic procedures. Very few clinical interventions are of no value in every clinical circumstance, and efforts to label interventions as being so will meet with professional resistance. In the context of complex and highly individualised clinical decisions, nuanced clinical judgements of experienced and well informed clinicians are likely to outperform any service-level measurement and incentive program aimed at recognising and reducing low-value care. Public policy interventions should focus on supporting clinician-led efforts to seek professional consensus on what constitutes low-value care and the best means for reducing it.

Identifying and acting on potentially inappropriate care.

OBJECTIVE: To develop a model to measure potentially inappropriate care in Australian hospitals. DESIGN: Secondary analysis of computerised hospital discharge data for all Australian hospitals for the 2010-11 financial year. MAIN OUTCOME MEASURE: Hospital-specific incidence of selected diagnosis-procedure pairs identified as inappropriate in other literature. RESULTS: Five hospital procedures that are not supported by clinical evidence happened more than 100 times a week, on average. The most frequent of these do-not-do treatments was hyperbaric oxygen therapy for a range of specific conditions (4659 admissions in 2010-11). The rate of do-not-do procedures varied greatly, even among comparator hospitals that provided the procedure and that treated the relevant patient group. Among comparator hospitals, an average of 3.3% of patients with osteoarthritis of the knee received arthroscopic lavage and debridement of the knee (a do-not-do treatment), but four hospitals had rates of over 20%. There was also great variation in hospital-specific rates of procedures that should not be done routinely. CONCLUSION: Hospital-specific rates of do-not-do treatments vary greatly. Hospitals should be informed about their relative performance. Hospitals that have sustained, high rates of do-not-do treatments should be subject to external clinical review by expert peers.

Can Alberta's primary care networks provide any lessons for Medicare Locals?

Australia's Medicare Locals are in a formative period, and any comparison so far has focused on the United Kingdom.

Design of price incentives for adjunct policy goals in formula funding for hospitals and health services.

BACKGROUND: Hospital policy involves multiple objectives: efficiency of service delivery, pursuit of high quality care, promoting access. Funding policy based on hospital casemix has traditionally been considered to be only about promoting efficiency. DISCUSSION: Formula-based funding policy can be (and has been) used to pursue a range of policy objectives, not only efficiency. These are termed 'adjunct' goals. Strategies to incorporate adjunct goals into funding design must, implicitly or explicitly, address key decision choices outlined in this paper. SUMMARY: Policy must be clear and explicit about the behaviour to be rewarded; incentives must be designed so that all facilities with an opportunity to improve have an opportunity to benefit; the reward structure is stable and meaningful; and the funder monitors performance and gaming.

Developing 'robust performance benchmarks' for the next Australian Health Care Agreement: the need for a new framework.

If the outcomes of the recent COAG meeting are implemented, Australia will have a new set of benchmarks for its health system within a few months. This is a non-trivial task. Choice of benchmarks will, explicitly or implicitly, reflect a framework about how the health system works, what is important or to be valued and how the benchmarks are to be used. In this article we argue that the health system is dynamic and so benchmarks need to measure flows and interfaces rather than simply cross-sectional or static performance. We also argue that benchmarks need to be developed taking into account three perspectives: patient, clinician and funder. Each of these perspectives is critical and good performance from one perspective or on one dimension doesn't imply good performance on either (or both) of the others.The three perspectives (we term the dimensions patient assessed value, performance on clinical interventions and efficiency) can each be decomposed into a number of elements. For example, patient assessed value is influenced by timeliness, cost to the patient, the extent to which their expectations are met, the way they are treated and the extent to which there is continuity of care.We also argue that the way information is presented is important: cross sectional, dated measures provide much less information and are much less useful than approaches based on statistical process control. The latter also focuses attention on improvement and trends, encouraging action rather than simply blame of poorer performers.

The Australian health care system: reform, repair or replace?

A Festshrift gives us the opportunity to look both backwards and forwards. Ken Donald's career stretches back to his intern days in 1963 and has encompassed clinical and population health, academe, clinical settings and the bureaucracy, and playing sport at state and national levels. There has been considerable change in the health care system over the period of Ken's involvement in the sector with more change to come -- where have those changes left us? This paper discusses these changes in relation to performance criteria.

The incidence and cost of cardiac surgery adverse events in Australian (Victorian) hospitals 2003-2004.

The aim of this study was to estimate the incidence of adverse events in acute surgical admissions for cardiac disease in admitted episodes in the year 2003-2004 and to estimate the cost of these complications to the Victorian health system. Cardiac surgery adverse events are among the most frequent and significant contributors to the morbidity, mortality and cost associated with hospitalisation. Patient-level costing data set for major Victorian public hospitals in 2003-2004 was analysed for adverse events using C-prefixed markers, denoting complications that arose during the course of hospital treatment for cardiac surgery diagnosis related groups (DRGs). The cost of adverse events was estimated by linear regression modelling, adjusted for age and co-morbidity. A total of 16,766 multi-day cardiac disease cases were identified, of whom 6,181 (36.85%) had at least one adverse event. Patients with adverse events stayed approximately 7 days longer and had four times the case fatality rate than those without. After adjustment for age and co-morbidity, the presence of an adverse event adds AUS$5,751. The sum of the total cost of adverse events for each DRG was AUS$42.855 million, representing 21.6% of total expenditure on cardiac surgery and adding 27.5% in broad terms to the cardiac surgery budget.

A new approach to clinical governance in Queensland.

Clinical governance approaches in Queensland health were trenchantly criticised in 2005 by two external reviews. In designing the new approach to clinical governance it was recognised that clinical governance should not be seen as only being about traditional safety and quality policies. A range of levers and policy instruments have been used in Queensland health to effect a new approach to clinical governance.

Developing a policy simulator at the acute-aged care interface.

This paper describes the development of a computer simulation of the interactions between the acute and aged care systems in Australia, using system dynamics modeling enhanced by agent-based techniques. National and regional simulations will be developed, enabling the impact of a variety of policy scenarios to be forecast over the next 10 years. The paper includes a description of the relevant policy environment and some of the associated key policy issues.

Health workforce design for the 21st century.

The Australian health workforce has changed dramatically over the last 4 years, growing in size and changing composition. However, more changes will be needed in the future to respond to the epidemiological and demographic transition of the Australian population. A critical issue will be whether the supply of health professionals will keep pace with demand. There are current recorded shortages of most health professionals, but this paper argues that future workforce planning should not be based on providing more of the same. Rather, the roles of health professionals will need to change and workforce planning needs to place a stronger emphasis on issues of workforce substitution, that is, a different mix of responsibilities. This will also require changes in educational preparation, in particular an increased emphasis on interprofessional work and common foundation learning.

Private care and public waiting.

Waiting time for public hospital care is a regular matter for political debate One political response has been to suggest that expanding private sector activity will reduce public waiting times. This paper tests the hypothesis that increased private activity in the health system is associated with reduced waiting times using secondary analysis of hospital activity data for 2001-02. Median waiting time is shown to be inversely related to the proportion of public patients. Policymakers should therefore be cautious about assuming that additional support for the private sector will take pressure off the public sector and reduce waiting times for public patients.

Board self-evaluation: the Bayside Health experience.

Board evaluation is a critical component of good governance in any organisation. This paper describes the board self-evaluation process used by Bayside Health, a public health service in Melbourne. The question of how governing boards can assess their performance has received increasing attention over the past decade. In particular, the increasing demand for accountability to shareholders and regulators experienced by corporate sector Boards has resulted in greater scrutiny of board performance, with the market and the balance sheet providing some basis for assessment. Performance evaluation of governing boards in the public sector has been more challenging. Performance evaluation is complex in a sector that is not simply driven by the bottom line, where the stakeholders involve both government and the broader community, and where access to, and the quality and safety of the services provided, are often the major public criteria by which performance may be judged. While some practices from the corporate sector can be applied successfully in the public sector, this is not always the case, and public sector boards such as the Board of Directors of Bayside Health have been developing ways to evaluate and improve their performance.

Drug policy down under: Australia's pharmaceutical benefits scheme.

Australia has had a government subsidized universal system of pharmaceutical provision for 50 years. The Pharmaceutical Benefits Scheme (PBS) consumes around 14 percent of total government health care expenditures and has grown substantially in both range of drugs covered, and expenditure since it was first introduced in 1950. It incorporates patient copayments (with differentials for the general population compared with concessional beneficiaries). Prior to listing a drug on the PBS it is subject to a rigorous cost-effectiveness analysis.