Differences and comparative declines in ischaemic heart disease mortality among subpopulations in Australia, 1969-1978.

Mortality rates from ischaemic heart disease (IHD) in Australia for the period 1969-78 have been analysed by place of residence, occupation and country of birth. Large variations were found among subpopulations. Throughout the period IHD mortality was lowest among professional and farming occupations and highest among workers in mining, transport and communications. Geographically, mortality from IHD was highest on the east coast and lowest in Western Australia. Mortality among immigrants was lower than among people born in Australia, with death rates for those born in Greece, Italy and Yugoslavia about half the average rates. Mortality from IHD in Australia has declined by about 25% over the last decade. However, the decline has not occurred uniformly. By occupation, the professional, technical and related workers showed the largest decline, while administrative, executive and managerial workers experienced the smallest decline. By place of residence in Australia, the largest declines occurred in the Hunter and Geelong regions, although the Hunter region still has the highest rate. Western Australia, excluding Perth, and rural Victoria did not show any marked decline. The remaining regions particularly the capital cities all experienced similar declines. When analysed by country of birth, Australian born residents showed a greater decline, while men born in Greece and Italy may have had an increase in IHD mortality. There is every indication that the decline will continue. Even those subpopulations with low initial IHD mortality experienced the decline, thus Perth and Adelaide (with low rates) had similar declines to Brisbane and Sydney (with high rates) and the professional occupation group which had the lowest rate also experienced the greatest decline.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimating potential savings in cancer deaths by eliminating regional and social class variation in cancer survival in the Nordic countries.

STUDY OBJECTIVES: To examine equity in the health care system with regard to cancer patient care by estimating the level of systematic regional variation in cancer survival in the Nordic countries. Specifically, those cancer sites which exhibit high levels of systematic regional variation in survival and hence inequity were identified. Estimating the reduction in cancer deaths which could be achieved by eliminating this variation so that everyone receives effective care will provide a readily interpretable measure of the amount of systematic regional variation. A comprehensive analysis of regional variation in survival has not previously been conducted so appropriate statistical methodology must be developed. SETTING AND PARTICIPANTS: All those aged 0-90 years who had been diagnosed with at least one of 12 common malignant neoplasms between 1977 and 1992 in Denmark, Finland, Norway, and Sweden. DESIGN: A separate analysis was conducted for each country. Regression models for the relative survival ratio were used to estimate the relative risk of excess mortality attributable to cancer in each region after correcting for age and sex. An estimate of the amount of systematic regional variation in survival was obtained by subtracting the estimated expected random variation from the observed regional variation. An estimate was then made of the potential reduction in the number of cancer deaths for 2008-12 if regional variation in survival were eliminated so that everyone received the same level of effective care. MAIN RESULTS: Between 2008 and 2012, an estimated 2.5% of deaths from cancers in the 12 sites studied could be prevented by eliminating regional variation in survival. The percentage of potentially avoidable deaths did not depend on country or sex but it did depend on cancer site. There was no relationship between the level of regional variation in a given country and the level of survival. The cancer sites for which the greatest percentage savings could be achieved were melanoma (11%) and cervix uteri (6%). The sites for which the highest number of deaths could be prevented were prostate, colon, melanoma, and breast. CONCLUSIONS: This methodology showed a small amount of systematic regional variation in cancer survival in the Nordic countries. The cancer sites with high levels of regional variation identified are potential targets for cancer control programmes.

Analysing differences in clinical outcomes between hospitals.

OBJECTIVE: To examine the variation between hospitals in rates of severe intraventricular haemorrhage (IVH) in preterm babies adjusting for case mix and sampling variability. DESIGN: Cross sectional study of pooled data from 1995 to 1997. SETTING: 24 neonatal intensive care units (NICUs) in the Australian and New Zealand Neonatal Network. PARTICIPANTS: 5413 infants of gestational age 24-30 weeks. MAIN OUTCOME MEASURES: Crude rates of severe (grades 3 and 4) IVH and rates adjusted for case mix using logistic regression, and for sampling variability using shrinkage estimators. RESULTS: The overall rate of severe IVH was 6.8%, but crude rates for individual units ranged from 2.9 to 21.4%, with interquartile range (IQR) 5.7-8.1%. Adjusting for the five significant predictor variables--gestational age at birth, 1 minute Apgar score, antenatal corticosteroids, transfer after birth, and sex--actually increased the variability in rates (IQR 5.9-9.7%). Shrinkage estimators, which adjust for differences in unit sizes and outcome rates, reduced the variation in rates (IQR 6.3-7.5%). Adjusting for case mix and using shrinkage estimators showed that one unit had a significantly higher adjusted rate than expected, while another was significantly lower. If all units could achieve an average rate equal to the 20th centile (5.74%), then 60 cases of severe IVH could be prevented in a 3 year period. CONCLUSIONS: The use of shrinkage estimators may have a greater impact on the variation in outcomes between hospitals than adjusting for case mix. Greater reductions in morbidity may be achieved by concentrating on the best rather than the worst performing hospitals.

The reliability and stability of a quantity-frequency method and a diary method of measuring alcohol consumption.

The study aimed to assess the test-retest reliability of two commonly used measures of alcohol consumption, the quantity-frequency (QF) method and the diary method, as well as the stability of scores on the two measures over time. Two methods of assessing reliability and stability were employed. The first was a traditional method based on calculation of correlation coefficients for agreement between scores on repeated measures over a short retest interval to yield test-retest reliability coefficients, and over a long retest interval to yield stability coefficients. The second method was that devised by Wiley and Wiley (1970) to differentiate the effects of reliability and stability on repeated measures over time. The two methods were applied to a sample of heavy drinkers and to a sample of light drinkers. The results indicated that both the QF and diary measures are reliable in measuring alcohol consumption of light drinkers. Both measures are less reliable for heavy drinkers. The results indicate, in addition, that drinking consumption levels of light drinkers demonstrate a high degree of stability. However, the consumption levels of heavy drinkers demonstrate less stability, especially over a long time period. Heavy drinkers significantly reduced reported levels of alcohol consumption on both measures after the first test, suggesting a regression to the mean effect or the possibility of unintended intervention effects due to repeated measurement of drinking behaviour.

Agreement between two measures of alcohol consumption.

Responses on the Quantity-Frequency Questionnaire (QF) were compared with those on the self-report diary. The QF was administered to 778 general practice patients prior to their consultation and the same patients completed the diary at home within 24 hours. The diary overestimated the number of nondrinkers in the population relative to the QF and classified a higher proportion of patients as heavy drinkers. The QF failed to detect 78% of heavy drinkers identified by the diary. Significantly (p less than .001) more alcohol was reported to be consumed overall on the diary (mean, 10.51 drinks/week) than on the QF (mean, 6.87 drinks/week). The relationship between responses on the two measures was nonlinear. At low consumption levels patients indicated drinking twice as much on the diary as on the QF, but the magnitude of the reported consumption difference decreased with increasing consumption levels. The results are discussed in terms of their implications for self-report measures of alcohol consumption.

Comparison of a quantity-frequency method and a diary method of measuring alcohol consumption.

This study compared the results obtained with two measures of alcohol consumption, a quantity-frequency (QF) method and a retrospective diary method, using a worksite sample. In order to control for the possibility of order effects, a subsample was chosen for readministration of the alcohol measures, when the order of presentation of the two measures was reversed for half of the subsample. Varying the order of presentation of the alcohol consumption items did not significantly affect the results obtained, except for an interaction effect between drinking group and order of presentation. Although subjects reported greater alcohol use on the diary than on the QF method at lower levels of consumption, the findings were reversed for higher levels of consumption. The relationship between the two measures is linear, with slope less than 1. Overall, subjects reported statistically significantly more alcohol consumption on the diary (mean [+/- SD] = 18.3 +/- 19.1 drinks) than on the QF method (mean = 16.9 +/- 19.5 drinks). The diary measure identified 20.9% of drinkers reporting consumption of more than 28 drinks per week, compared with 17.8% for the QF. However, the diary measure identified only 10.6% of drinkers reporting more than 42 drinks per week, compared with 10.2% for the QF. Consequently, the usefulness of the diary in detecting heavy drinkers appears to decrease with increasing consumption. These findings suggest the need for careful selection of alcohol consumption measures for research purposes and the need for caution in comparing the results of studies using different measures of alcohol consumption.

The relationships between high-risk and problem drinking and the occurrence of work injuries and related absences.

A review of studies on the relationship between alcohol and work injuries revealed that the evidence is contradictory and that many of the studies contain methodological flaws. The present study aimed to determine whether there are relationships between problem drinking and high alcohol consumption and outcomes such as work injuries and related absences. The sample consisted of 833 employees at an industrial worksite. Problem drinking was measured by the Mortimer-Filkins test, while alcohol consumption was measured by a 7-day retrospective diary. Work injury data were obtained from medical reports completed at the worksite medical center, while absences data were obtained from company records. Chi-square analyses revealed significant relationships between problem drinking and work injuries and injury-related absences, but not between high alcohol consumption and work injuries and related absences. Logistic regression analysis revealed that no variables were significant predictors of work injuries. However, when uninjured subjects were excluded, a second analysis revealed that Mortimer-Filkins test scores, recent stressful life events, age and job satisfaction were significant predictors of two or more injuries. Injured subjects were almost twice as likely to have two or more injuries if they had high numbers of recent stressful life events and low levels of job satisfaction. Logistic regression analysis revealed that age, Mortimer-Filkins test categories and job satisfaction significantly predicted injury-related absences. Problem drinkers were 2.7 times more likely to have injury-related absences than non-problem drinkers, and subjects with low levels of job satisfaction were 2.2 times more likely than others to have injury-related absences. The implications of the results for workplace alcohol policies and programs are discussed.

Methodological issues in interpreting trends in MONICA event rates.

Before looking at the trends in coronary event rates and case fatality rates in the WHO MONICA Project, it is necessary to assess the consistency and validity of the data. In the Newcastle MONICA Collaborating Centre, two methods have been used. One involves monitoring data quality by comparisons with external data systems such as hospital discharge data and official mortality records. The other is to examine the internal consistency of MONICA diagnostic findings. For fatal myocardial infarction (MI) or coronary death, there is consistent evidence of a decline, but the MONICA data are not adequate to assess relative changes in sudden compared to non-sudden death rates. For non-fatal definite MI there was an increase early in the study, possibly due to a change in methods, but rates have now stabilized. For non-fatal possible MI there has been a steady increase in rates for events which may be becoming less severe. This is consistent with increasing hospital admissions for subacute ischaemic heart disease (IHD) and angina. This paper exemplifies the importance of maintaining internal and external surveillance of the quality of the data.

Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital.

OBJECTIVE: To assess the frequency and nature of adverse events to patients in selected hospitals in developing or transitional economies. DESIGN: Retrospective medical record review of hospital admissions during 2005 in eight countries. SETTING: Ministries of Health of Egypt, Jordan, Kenya, Morocco, Tunisia, Sudan, South Africa and Yemen; the World Health Organisation (WHO) Eastern Mediterranean and African Regions (EMRO and AFRO), and WHO Patient Safety. PARTICIPANTS: Convenience sample of 26 hospitals from which 15,548 patient records were randomly sampled. MAIN OUTCOME MEASURES: Two stage screening. Initial screening based on 18 explicit criteria. Records that screened positive were then reviewed by a senior physician for determination of adverse event, its preventability, and the resulting disability. RESULTS: Of the 15,548 records reviewed, 8.2% showed at least one adverse event, with a range of 2.5% to 18.4% per country. Of these events, 83% were judged to be preventable, while about 30% were associated with death of the patient. About 34% adverse events were from therapeutic errors in relatively non-complex clinical situations. Inadequate training and supervision of clinical staff or the failure to follow policies or protocols contributed to most events. CONCLUSIONS: Unsafe patient care represents a serious and considerable danger to patients in the hospitals that were studied, and hence should be a high priority public health problem. Many other developing and transitional economies will probably share similar rates of harm and similar contributory factors. The convenience sampling of hospitals might limit the interpretation of results, but the identified adverse event rates show an estimate that should stimulate and facilitate the urgent institution of appropriate remedial action and also to trigger more research. Prevention of these adverse events will be complex and involves improving basic clinical processes and does not simply depend on the provision of more resources.

Understanding variation: the key to cost reduction and quality improvement.

Analyses of acute hospital services in Australia reveal geographic differences in the rates of utilization. In order to meet the important challenge of improving the quality of services it is necessary to understand the nature and causes of the variation in these utilization measures. This paper provides examples of the variation in admission rates and lengths of stay for selected procedures in Australian States and shows that the length of stay is related to the variation in admission rates. It concludes that a greater understanding of both the admission and discharge processes is necessary to improve quality and produce cost savings.

Monitoring postoperative pulmonary embolisms in Australia--I. Variation between hospitals.

Information on inter-hospital variation in clinical outcomes can be extracted from routinely collected morbidity data in Australia. Postoperative pulmonary embolism rates, one of seven clinical performance indicators now subject to review during Australian hospitals' quality accreditation surveys, is used as an example throughout. Using indirect statistical standardisation and Poisson models of random variation, we were able to identify five hospitals which recorded statistically significantly higher pulmonary embolism rates than average and three which recorded lower than expected rates. The application of these methods to all hospital outcome measures will assist in objectively monitoring the quality of patient care.

Monitoring postoperative pulmonary embolisms in Australia--II. Variation within hospitals.

Clinical indicator data can be analysed quickly and efficiently within hospitals to provide quality review staff with monthly or quarterly reports on their own hospital's performance relative to national or regional normative statistics. The statistical tools used are indirect standardisation to correct for casemix differences between institutions and control charts, and cumulative sum charts for the analysis and presentation of findings. Routinely collected postoperative pulmonary embolism data are used to illustrate these approaches.

Survival of patients with colorectal cancer detected by a community screening program.

OBJECTIVE: To determine survival rates for people with colorectal cancer detected through Bowelscan, a community screening program. DESIGN: Survey of data from local medical practitioners, and comparison with data from State cancer registries. SUBJECTS AND SETTING: 249 people with colorectal cancer detected after faecal occult blood screening in north-eastern New South Wales, 1987-1996. Follow-up was in 1998-1999. MAIN OUTCOME MEASURES: Five-year survival rates and relative survival ratios. RESULTS: Five-year survival rates for the screen-detected cancer patients were 90% for those with Dukes' stage A cancers, 75% for Dukes' B, 52% for Dukes' C and 0 for Dukes' D (although one person with Dukes' D cancer was living at four-year follow-up at the end of the study). Because of the higher percentage of Dukes' A cases in the population whose cancer was detected through screening, the resulting five-year relative survival ratio was significantly better than for those recorded by New South Wales, South Australian and Queensland cancer registries: 0.82 (95% confidence interval, 0.74-0.90) compared to 0.59 (P < or = 0.001). CONCLUSIONS: The study supports the findings of three overseas randomised trials that screening reduces mortality from colorectal cancer. We estimate that screening 200,000 people would detect about 250 colorectal cancers and prevent as many as 55 deaths.

Patient satisfaction with day surgery.

OBJECTIVE: To assess patient satisfaction with day surgery facilities in New South Wales public hospitals. METHOD: One hundred and fifty patients from each of 8 day surgery units were asked to complete a self-administered questionnaire to assess satisfaction with their day surgery experience, including details on their admission, care and postoperative course. The questionnaire responses were anonymous and there was no follow-up of non-respondents. RESULTS: The overall response rate to the questionnaire was 37.3%. There was considerable variation in response rates across hospitals, ranging from a low of 14.7% to a high of 52.7%. Three procedures accounted for 55% of responses: endoscopies of the gastrointestinal tract (21.7%), gynaecological procedures (18.3%) and eye procedures (16.3%). Day surgery was generally well accepted. Of all the respondents, 78.4% would recommend day surgery to others and 94.2% would recommend the day surgery unit that they used. Respondents found their day surgery experience to be as they had expected or less worrying than expected in 87.0% of cases. The proportion requiring hospital readmission in the seven day postoperative period was 2.7%. The survey showed that the units operated quite differently in two aspects of day surgery provision: the scheduling of patient admissions; and post-discharge contact with patients to check on their recovery.

Death certification and coding for ischemic heart disease in Australia.

Trends in ischemic heart disease mortality are of current interest because death rates have declined rapidly in the United States, Australia, and some other countries during the last decade, although they have risen elsewhere. There is a need to assess the quality of the data from which such trends are calculated and to consider what information will be required to monitor accurately future patterns of incidence and mortality for this disease. This paper describes two investigations of routinely collected mortality data for ischemic heart disease in Australia. First, information obtained from a heart attack surveillance study was compared with officially recorded causes of death for a defined population during 1979. Second, mortality trends from 1969 to 1978 were compared between the major Australian states. Both studies showed that mortality data were accurate to within about 10%. However, for acute myocardial infarction and other subcategories of ischemic heart disease, the data were neither valid nor reliable. New diagnostic and coding practices are required before it will be possible to monitor accurately long-term trends in subcategories of ischemic heart disease.

Mortality in the Hunter Region, New South Wales, 1970 to 1977.

For the past two decades, crude mortality rates for the Hunter Health Region of New South Wales have been consistently higher by about 5% than those for the State in general. This is, in part, attributable to a concentration of deaths, particularly of those from ischaemic heart disease and stroke, in two major industrial areas within the Region. Favourable modification of these mortality inequalities may be possible in some cases through legislation and education. The importance of these inequalities for planning health care resources is also discussed.

Adverse events in surgical patients in Australia.

OBJECTIVE: To determine the adverse event (AE) rate for surgical patients in Australia. DESIGN: A two-stage retrospective medical record review was conducted to determine the occurrence of AEs in hospital admissions. Medical records were screened for 18 criteria and positive records were reviewed by two medical officers using a structured questionnaire. SETTING: Admissions in 1992 to 28 randomly selected hospitals in Australia. STUDY PARTICIPANTS: Five hundred and twenty eligible admissions were randomly selected from in-patient database in each hospital. A total of 14,179 medical records were reviewed, with 8747 medical and 5432 surgical admissions. MAIN OUTCOME MEASURES: Measures included the rate of AEs in surgical and medical admissions, the proportion resulting in permanent disability and death, the proportion determined to be highly preventable, and the identification of risk factors associated with AEs. RESULTS: The AE rate for surgical admissions was 21.9%. Disability that was resolved within 12 months occurred in 83%, 13% had permanent disability, and 4% resulted in death. Reviewers found that 48% of AEs were highly preventable. The risk of an AE depended on the procedure and increased with age and length of stay. CONCLUSION: The high AE rate for surgical procedures supports the need for monitoring and intervention strategies. The 18 screening criteria provide a tool to identify admissions with a greater risk of a surgical AE. Risk factors for an AE were age and procedure, and these should be assessed prior to surgery. Prophylactic interventions for infection and deep vein thrombosis could reduce the occurrence of AEs in hospitals.

Determinants of non-compliance with short term antibiotic regimens.

The contribution of doctor, patient, and consultation interaction patterns to compliance with antibiotic treatment was examined in 233 adult patients seen in general practice. Twelve variables were shown to discriminate between compliers and non-compliers. Discriminating variables relating to patients included health state, employment state, knowledge of tablet, and perception of anxiety level, difficulty in complying, and their observed anger, distance, and assertiveness in the consultation. Discriminating variables relating to doctors included provision of advice on duration of treatment, complexity of dosage schedule, age of doctor, and number of years in practice. For the most part these results confirmed previous research. It is concluded that the doctor should consider both the dosage schedule and the patient's daily routine when prescribing antibiotic tablets. Advice on how to take the tablets should be given in specific rather than in general terms. The significant effect of the age of the doctor and the years spent in practice has not been found in previous work. This finding may reflect differences in behavior between younger doctors and their patients. This difference was not detected in the observation of consultation events.