Using systems thinking and the Intervention Level Framework to analyse public health planning for complex problems: Otitis media in Aboriginal and Torres Strait Islander children.

BACKGROUND: Middle ear disease (otitis media) is endemic among Aboriginal and Torres Strait Islander children in Australia and represents an important cause of hearing loss. The disease is the result of a mix of biological, environmental and host risk factors that interact in complex, non-linear ways along a dynamic continuum. As such, it is generally recognised that a holistic, systems approach is required to reverse the high rates of otitis media in Aboriginal and Torres Strait Islander children. The objective of this paper is to examine the alignment between efforts designed to address otitis media in Aboriginal and Torres Strait Islander children in Queensland, Australia and core concepts of systems thinking. This paper's overall purpose is to identify which combination of activities, and at which level, hold the potential to facilitate systems changes to better support ear health among Aboriginal and Torres Strait Islander children. METHODS: We began with a review of documents identified in consultation with stakeholders and an online search. In addition, key informants were invited to participate in an online survey and a face-to-face or phone interview. Qualitative interviews using a semi-structured interview guide were used to explore survey responses in more depth. We also undertook interviews at the community level to elicit a diverse range of views. Ideas, statements or activities reported in the documents and interviews as being performed under the Intervention Level Framework were identified using qualitative thematic and content analysis. A quantitative descriptive analysis was also undertaken, whereby data was extracted into an Excel spreadsheet and coded under the relevant strategic directions and performance indicators of the Framework. Subsequently, we coded activities against the five-level intervention framework developed by Malhi and colleagues, that is: 1) paradigm; 2) goals; 3) system structure; 4) feedback and delays; and 5) structural elements. RESULTS: Overall, twenty documents were reviewed. We examined surveys and interviews with six key informants. Twenty-four individual and 3 group interviews were conducted across central and community level informants. One hundred and four items were coded from the 20 documents and 156 items from interview data. For both data sets, the majority of activities were coded at the structural elements level. The results suggested three key areas where further work is needed to drive sustained improvements: 1) build the governance structures needed for paradigm shift to achieve a multi-sectoral approach; 2) develop shared system level goals; 3) develop system-wide feedback processes. CONCLUSIONS: Sustained progress in improving ear health within Aboriginal and Torres Strait Islander children requires a holistic, system-wide approach. To advance such work, governance structures for multi-sectoral collaboration including the development of joint goals and monitoring and feedback are required. Intervening at these higher leverage points could have a profound effect on persistent public health issues.

Over 150 potentially low-value health care practices: an Australian study.

OBJECTIVE: To develop and apply a novel method for scanning a range of sources to identify existing health care services (excluding pharmaceuticals) that have questionable benefit, and produce a list of services that warrant further investigation. DESIGN AND SETTING: A multiplatform approach to identifying services listed on the Australian Medicare Benefits Schedule (MBS; fee-for-service) that comprised: (i) a broad search of peer-reviewed literature on the PubMed search platform; (ii) a targeted analysis of databases such as the Cochrane Library and National Institute for Health and Clinical Excellence (NICE) "do not do" recommendations; and (iii) opportunistic sampling, drawing on our previous and ongoing work in this area, and including nominations from clinical and non-clinical stakeholder groups. MAIN OUTCOME MEASURES: Non-pharmaceutical, MBS-listed health care services that were flagged as potentially unsafe, ineffective or otherwise inappropriately applied. RESULTS: A total of 5209 articles were screened for eligibility, resulting in 156 potentially ineffective and/or unsafe services being identified for consideration. The list includes examples where practice optimisation (ie, assessing relative value of a service against comparators) might be required. CONCLUSION: The list of health care services produced provides a launchpad for expert clinical detailing. Exploring the dimensions of how, and under what circumstances, the appropriateness of certain services has fallen into question, will allow prioritisation within health technology reassessment initiatives.

Diagnostic performance of serum cobalamin tests: a systematic review and meta-analysis.

AIMS: Serum cobalamin (cbl, vitamin B(12)) tests are routinely ordered for investigating conditions potentially amenable to cbl supplementation. This study aimed to systematically assess the evidence of diagnostic accuracy for serum cbl tests across patient subgroups. METHODS: Seven medical databases were searched (1990 to November 2009). Studies were included that compared serum cbl to a reference standard (all reference standards employed). Study quality was assessed using QUADAS. Summary estimates of test performance were determined using the bivariate model and hierarchical summary receiver operating characteristic curves (HSROC). RESULTS: Of 2878 identified studies, 54 were included. Studies rated poorly against QUADAS criteria. Positive (PLR) and negative likelihood ratios (NLR) were 2.72 [95% confidence interval (CI) 1.95, 3.81] and 0.59 (0.49, 0.72), respectively (studies employing methylmalonic acid as the referent). In studies employing a clinical reference standard, PLR was 3.33 (0.92, 12.10) and NLR 0.34 (0.13, 0.89). Test performance did not vary by clinical indication, test method or age. CONCLUSION: This review was limited by the quality of the evidence base and lack of a gold standard. From the available evidence, diagnosis of conditions amenable to cbl supplementation on the basis of serum cbl level alone cannot be considered a reliable approach to investigating suspected vitamin deficiency.

Measuring quality.

It is no longer sufficient for health care professionals to provide high quality health care, they must also be able to demonstrate that they are meeting and often exceeding quality targets. Quality indicators (QIs) provide a means of measuring and assessing quality, however there are advantages and disadvantages of indicator measurement. Further, the clinical perspective needs to be balanced against managerial control when developing valid, reliable, sensitive and specific QIs. While indicators do not represent a perfect measurement device, they may provide a useful tool for improving patient safety and meeting community expectations.