A national clinical indicator database: issues of reliability and validity.

The introduction of performance (clinical) indicators into the accreditation process by the Australian Council on Healthcare Standards is in keeping with global trends and has enabled the establishment of a National Aggregate Database reflecting standards of care in acute health care organisations. The database contains both quantitative and qualitative information on the processes and outcomes of patient care and changes in practice induced through indicator monitoring. Of fundamental importance to the integrity of the database are the issues of indicator validity, responsiveness and reliability. This paper considers these issues, drawing parallels, as appropriate, to other performance indicator programs and studies.

Hospital characteristics associated with unplanned readmissions.

The rate of unplanned readmission of patients to hospitals has been introduced into the Australian Council on Healthcare Standards accreditation program as an internal flag of problems in patient management and outcome. An emphasis, in the indicator definition, is placed on the unexpected nature of the admissions to exclude those which are unplanned but simply due to progression of a disease, and are therefore not 'unexpected'. The association of hospital characteristics with unplanned readmissions was examined using logistic regression on the data collected from hospitals surveyed in 1993. The risk of unplanned readmission was significantly higher in public hospitals than in private hospitals. Hospital bed-size also reflected differences in the risk of unplanned readmission, being significantly higher for hospitals with over 200 beds than for those with 1-100 beds. In rural areas, the risk of unplanned readmission was significantly lower in hospitals with 101-200 beds and over 200 beds compared to hospitals with 1-100 beds (p for trend = .004). However, in metropolitan areas, the risk of unplanned readmission increased with the size of the hospitals (p for trend < .0001). Monitoring of unplanned readmissions prompted internal clinical review and action in 31 per cent of hospitals, demonstrating the indicator's usefulness as an internal quality tool. However, the use of unplanned readmissions as an external performance measure must take into account a hospital's characteristics and will remain of limited value in the absence of clinical information about the expected or unexpected nature of the readmissions.

Clinical indicators as a stimulus to QA in hospitals an early report.

To increase medical staff involvement in hospital quality assurance activities and to increase the clinical component of a hospital accreditation process, the Australian Council on Health Standards (ACHS) through its Care Evaluation Program (CEP) has combined with the Medical Colleges, which are the professional associations for surgeons, internists, etc. Objective measures of care (clinical indicators) have been developed, and the first set (Hospital Wide Medical Indicators--HWMIs) was introduced into the Accreditation process from January 1993. Both quantitative and qualitative information is being received back by the Care Evaluation Program. The latter information reveals that the indicators have stimulated an increase in QA in hospitals.

Clinical indicators in accreditation: an effective stimulus to improve patient care.

The Australian Council on Healthcare Standards (ACHS) established the Care Evaluation Program (CEP) of clinical performance measures in its accreditation program to increase the clinical component of that program and to increase medical practitioner involvement in formal quality activities in their health care organizations. From the introduction of a set of generic indicators in 1993 the program expanded through all of the various medical disciplines and from January 2000 there will be 18 sets (well over 200 indicators) in the program. More than half of Australia's acute hospitals (covering the majority of patient separations) are monitoring the indicators and reporting clinical data twice yearly to the ACHS. In turn they receive a 6-monthly feedback of aggregate and peer comparative results. The ACHS policy had no specific requirement for a set number of indicators to be monitored and it was not mandatory to achieve any specific data threshold to be accredited. However, where an organization's results differed unfavorably from those of its peers some action was expected. Qualitative information is also sent to the CEP and this has enabled a determination of the effectiveness of the indicators. There is documented evidence of improved management and numerous examples of improved patient outcomes. The program remains unique in the scope of the medical disciplines covered and in the formal provider involvement with indicator development. Both the clinical component of accreditation and clinician involvement in quality activities have been increased in an educational process. However, not all of the indicators are of equal value and a reduction in the number of indicators to a 'core' group of the most reliable and responsive ones is in process.

Internal haemorrhoids: observations on their nature and classification in relation to their management.

Haemorrhoids become manifest as a result of enlargement and downward displacement of collections or cushions of submucosal tissue situated normally in the anal canal. The variation in the size of this tissue and the frequent lack of correlation between size and symptoms make assessment of the various forms of treatment difficult. An objective classification is outlined, together with a rational approach to treatment.

Improving appropriate use of surgical services.

The aspects of surgical services being addressed from the point of view of appropriateness in Australia at the present time are the use of the surgical bed, the maintenance of standards by the surgeon and the need for and outcome of the surgical procedures performed. There are growing waiting lists now for the 70% of acute hospital beds which are public. Whilst these waiting lists are inaccurate and require regular review their existence has led to a greater interest in reducing length of stay. This has hitherto not been of concern, with hernia patients for example staying five days or more. With regard to the surgeon it has been felt that the long training period (six years) guaranteed a high standard which was maintained. The Royal Australasian College of Surgeons is however, now to introduce a system of re-certification which will involve a demonstration of continuing education, the maintenance of an audit and a periodic physical examination. Delineation of privileges has until now only been in the broad traditional categories but consideration is being given to delineation of privileges for sophisticated surgery and particularly for new procedures (e.g. percutaneous cholecystectomy). Systems for assessing the quality of the surgery itself have been slow to develop, particularly in the smaller and private hospitals. Government bodies have been concerned in the private sphere with over servicing and a number of studies have been done showing regional variations in numbers of operations performed. Over servicing is, however, difficult to detect.(ABSTRACT TRUNCATED AT 250 WORDS)

Health-care performance measurement systems and the ACHS Care Evaluation Program. Australian Council on Healthcare Standards.

The call for evidence-based medicine and information on health outcomes has brought with it performance measurement systems. The necessary attributes of these systems are now being addressed as are the attributes of the measures themselves. In this paper the Australian Council on Healthcare Standards Care Evaluation Program is reviewed in relation to these various attributes. The more focused systems should prove useful in achieving change in clinical practice.

Extending facility accreditation to the evaluation of care: the Australian experience.

The Australian Council on Healthcare Standards (ACHS) has introduced clinical performance measures--clinical indicators--into the accreditation process. The indicators are developed with the assistance of the various medical colleges (professional associations of specialists). Sixteen such bodies are now in the program, with 150 draft indicators covering 90 areas of hospital practice. The development of a set of indicators passes through a number of stages to ensure their validity, and a process is in place to assess their reliability, reproducibility and responsiveness. The qualitative information available indicates a willingness on the part of health care facilities to address the indicators, and alter the process of care. It is anticipated that the quantitative information being collected in aggregate form will subsequently demonstrate an improvement in the outcome of care. Hospital specific information currently remains confidential to the ACHS and the particular health care facility. The public release of such information and the value of doing so remains undetermined.

The Australian development of national quality indicators in health care.

BACKGROUND: The Australian Council on Healthcare Standards (ACHS) conducts a voluntary program of health facility accreditation modeled along the lines of the Joint Commission. To increase clinician involvement in the accreditation process and in quality assurance programs and to enable some assessment of the outcome of care in a facility at the time of survey, the ACHS, together with the medical colleges, is developing objective measures of care (clinical indicators). METHODS: Ten medical colleges are now involved in the program. The first set of measures, the Hospital-Wide Medical Indicators (HWMIs) developed in conjunction with the Royal Australian College of Medical Administrators, was formally introduced into the accreditation process in January 1993. These indicators were developed by a combined working party of the Care Evaluation Program and the Royal Australian College of Medical Administrators. The HWMIs address the areas of trauma, postoperative pulmonary embolism, readmissions to hospital, returns to the operating room, hospital-acquired infection, medication errors, and hospital throughout. CONCLUSION: It is hoped that the development of objective measures of care (clinical indicators) will facilitate the accreditation process. The development of these measures also enables Australian physicians to compare patient care throughout the hospital with national indicators of quality of care.

Posthysterectomy rectal and vaginal prolapse, a commonly overlooked problem.

The existence of combined rectal and vaginal prolapse is more common than the literature would suggest. This paper outlines a further development in the operative management which has been applied to 24 patients with this problem. All had had a hysterectomy and most had had in addition one or more vaginal repairs. The common mode of presentation was one of pelvic pain (19 patients), sometimes severe, crippling and intractable and some form of protrusion (14 patients), difficult or unsatisfied defaecation and rectal incontinence (9 patients). The vaginal prolapse which always involved the vault and usually involved the lower vagina was usually found to be incomplete and the rectal prolapse complete (but occult). The operative procedure essentially consists of a Wells type rectopexy which has a new modification in which the sling is extended to anchor the vaginal vault after correction of the enterocele by the abdominal approach. A vaginal repair is subsequently performed at the same operation where anterior or posterior vaginal prolapse persists. Important points in the procedure are the avoidance of sepsis (the vaginal vault is not opened during the procedure) and protection of the ureters by careful assessment of the lateral margins of the vaginal vault which is illuminated by transvaginal vault endoscopy. At this early stage operative morbidity has been minimal, relief of the pelvic symptoms has been most encouraging, but the length of follow-up is short (range 6-30 months, average 15.6) and long-term evaluation will be necessary as with all surgery for prolapse.

Nosocomial infection indicators in Australian hospitals: assessment according to hospital characteristics.

The relationship of bed size and hospital type (private or public) was studied using Hospital-Wide Medical Indicator data on nosocomial infections submitted to the Australian Council on Healthcare Standards Care Evaluation Program by hospitals presenting voluntarily for accreditation in 1993. The aim was to determine if this process could simplify the establishment of hospital peer groups for comparison of risk in the absence of knowledge of patient illness severity indices. After adjusting for potential confounders in a logistic model, hospital type was found to be a significant predictor for the occurrence of infection in clean and contaminated wounds. Bed size was a significant predictor for the occurrence of hospital-acquired bacteraemia in private and public hospitals. The increase in the risk of developing hospital acquired bacteraemia with increasing number of beds was significant as a trend (P < 0.0001) in private as well as public hospitals. The results suggest that hospital type and bed size are initial indices for 'flagging' peer group variation and prompting a more detailed internal review.

Positive correlation between blood alcohol level and ISS in road trauma.

To assess the relationship between blood alcohol concentration (BAC) and injury severity in an unselected population of road accident victims, case notes of 820 consecutive road accident victims presenting to hospital in a 12 month period were reviewed retrospectively. Five hundred and thirty-five of these were eligible for BAC analysis and results, obtained from the Victoria Police and the Road Safety and Traffic Bureau were available in 429 cases. These were expressed as mg/100 ml (per cent). Injury severity was quantified using the Injury Severity Score (ISS). BAC was compared with injury severity in three ways. First, Spearman's correlation coefficient (rho) of 0.27 indicated a highly significant correlation (P < 0.01). Second, the median ISS for intoxicated patients (4) was significantly higher than that for sober patients (1) (P < 0.05). Third, when patients were grouped according to ISS, the prevalence of intoxication in each group rose with increasing injury severity (chi 2: P < 0.01). We conclude that there is a significant positive correlation between BAC and injury severity in road accident victims treated at a Melbourne hospital.

The risk of an unplanned return to the operating room in Australian hospitals.

BACKGROUND: The unplanned return of the patient to the operating room (OR) after a previous procedure has implications concerning the quality of surgery, but little has been written on this subject. METHODS: The relationship of bed-size and hospital type (private or public) was studied using data on this clinical indicator submitted to the Australian Council on Healthcare Standards Care Evaluation Program (ACHS CEP) by hospitals presenting voluntarily for accreditation in 1993. RESULTS: The mean rate of an unplanned return to OR was 0.6% (95% confidence interval 0.5-0.7). After adjusting for potential confounders in a logistic model, the risk of unplanned return to OR did not significantly differ by type of hospital (private or public), and location (rural, metropolitan). The risk of unplanned return to OR was higher in large compared with small hospitals. CONCLUSIONS: The finding of the risk of the event being greater in large compared with small hospitals is likely to be a reflection of casemix. An interval review of results (for any facility) is obviously necessary. With some operations a higher incidence of return to the OR may indicate vigilance in peri-operative management.

Use of the Injury Severity Score to monitor diagnostic accuracy in the early assessment of road trauma.

A retrospective review of 279 hospital admissions at two Melbourne hospitals was conducted to develop a method for identifying diagnostic error using the Injury Severity Score (ISS) as a model for clinical audit. Two scores were calculated for each patient, the first according to injuries diagnosed on initial assessment in the Emergency Department and the second according to final, confirmed diagnoses upon discharge from hospital. Diagnostic errors were identified as discrepancies between the initial and final scores. ISS discrepancies were found in 48 cases (17.2%). Some were clinically significant errors of diagnosis while others reflected inaccurate injury description or record keeping. Abdominal injuries were the most frequently missed, followed in decreasing order by spinal, thoracic, extremities (limbs), head/face and external injuries (skin and subcutaneous tissues). The frequency and pattern of injury misdiagnosis concurs with the findings of other studies. The diagnostic error rate was found to increase with injury severity and with the number of anatomic body regions involved. The authors suggest that comparing initial and final ISS provides a convenient mechanism for the audit of early diagnosis in trauma cases.

Assessment of postoperative pulmonary embolism as a measure of patient care.

Hospitals presenting voluntarily for accreditation survey during 1993 submitted data on pulmonary embolism to the Australian Council on Health Care Standard (ACHS) Care Evaluation Program (CEP) as a part of their medical quality activities. The data were stratified by hospital type and bed-size, and compared to the provisional threshold of 1%. The mean duration of data collection was 24 weeks (range 8-74 weeks). Of hospitals with bed-size 1-50, 77% observed a zero pulmonary embolism rate. Hospitals with zero and non-zero pulmonary embolism rates were significantly different with respect to bed-size (P = 0.001). The rarity of pulmonary embolism and lack of prospective continuous monitoring poses considerable problems in interpretation of aggregate rates. Hospitals with a high patient throughout should continuously monitor their pulmonary embolism data to achieve a large denominator. For smaller hospitals with a low performance of major operations, collection of data on this clinical indicator is unlikely to be useful as a measure of quality of care.

Primary adenocarcinoma of the appendix in an inguinal hernia.

Primary adenocarcinoma of the appendix and primary carcinomata within hernial sacs are both uncommon clinical problems. A previously undescribed presentation of primary adenocarcinoma of the appendix in a right sided sliding inguinal hernia is presented and discussed. It is important to follow up patients with carcinoma of the appendix in order to exclude other colonic lesions. The St Vincent's Hospital (Melbourne) experience in this condition is limited but parallels that of major series elsewhere.