Errors in health care management: what do they cost?

BACKGROUND: Iatrogenic injuries are relatively common and a potentially avoidable source of morbidity. The economic evaluation of this area has been limited by the lack of good quality national data to provide an estimate of incidence, associated disability, and preventability of iatrogenic injuries. Two recent surveys, the Quality in Australian Health Care Study (QAHCS) and the Utah Colorado Study (UTCOS), have now made this feasible. AIMS: To determine the direct costs associated with iatrogenic injuries occurring in a hospital setting. METHODS: The QAHCS was used as a representative national source of information on the incidence, disability, and preventability of iatrogenic injuries. Costs were calculated using information from Australian disease related groups (AN-DRGs) relative to the injury categories. RESULTS: The cost of just 12 preventable iatrogenic injuries is significant (0.25 million US dollars) and accounts for 2-3% of the annual budget of a typical Australian community based hospital of 120 beds. Costing data provide additional useful information for policy and decision makers. CONCLUSION: Costing iatrogenic injuries is an important component of the impact of these events. An ongoing national database of iatrogenic injuries is necessary to assist in identifying the incidence of these injuries, monitoring trends, and providing data for cost estimates and economic evaluations.

Reported diabetes mellitus management among South Australian general practitioners.

Diabetes mellitus is a chronic disease commonly managed in general practice. This article reviews the findings of a questionnaire survey of 173 randomly chosen South Australian general practitioners and their reported management in the areas of detection, diagnosis, assessment, monitoring and GP knowledge. Substantial differences between respondents were found in all areas, suggesting the need for improved educational methods aimed at all general practitioners.

Knowledge of and reported asthma management among South Australian general practitioners.

AIM: This study, carried out in 1989, set out to assess general practitioners' knowledge of asthma management and their reported management practices. METHOD: Of 153 randomly selected South Australian general practitioners 127 (83%) completed a questionnaire designed to explore issues relating to the management of asthma. RESULTS: The survey revealed substantial differences between general practitioners in their knowledge and management practices including the assessment of the severity of asthma, the need for objective monitoring, that is by the use of spirometry and peak flow meters, and the use of medication. Overall, the sampled general practitioners believed that patient-related factors were the main barriers to effective treatment of asthma. CONCLUSION: The findings of this study suggest that ideal asthma management was not being attained. More research is required to ascertain why such variability among practitioners exists and how best to remedy these differences.

Improving influenza vaccine coverage in at-risk groups. Good intentions are not enough.

OBJECTIVES: To raise awareness of the need for annual influenza vaccination in the elderly (those 65 years of age and older), and of the efficacy of organisational practice strategies (specifically at-risk registers and reminder systems) to improve influenza vaccine coverage. DATA SOURCES: Extensive search of the existing literature using MEDLINE and manual searching techniques. Recent key review articles on organisational strategies were also studied. STUDY SELECTION: Primary source articles were included if they evaluated the efficacy of vaccination and the various strategies used to improve coverage. More attention was paid to randomised controlled trials, although other study designs were considered. A formal algorithm for estimating the effect of organisational strategies was not used; rather, appropriate studies which highlighted advantages and disadvantages were selected. RESULTS: Current levels of vaccination for influenza are low. Negative patient attitudes and lack of an organised and systematic approach are the major barriers to improving vaccination rates. Vaccination coverage can be improved by 10%-30% by use of at-risk registers and reminder systems. CONCLUSIONS: Further research is required to determine the impact of both patient attitudes and reminder systems on influenza vaccination rates. A randomised controlled trial is currently underway to look at both these issues. Provider and patient reminder systems should be incorporated into general practice to improve the influenza vaccination rate.

Will facilitators be acceptable in Australian general practice? A before and after feasibility study.

AIM: To describe the impact of the 'facilitator model' of promotion on two Australian general practices. METHOD: Attitudes and health promotion levels were evaluated before and after the facilitator worked with two practices. RESULTS: Simple changes to patient records were the most successful. CONCLUSION: Facilitators are acceptable and long term organisational changes can be achieved.

South Australian hypertension survey. General practitioner experiences with drug treatment.

OBJECTIVE: To investigate prescribing habits, educational approaches and perceived needs of general practitioners in the drug treatment of hypertension. DESIGN, SETTING AND PARTICIPANTS: Of 156 randomly selected South Australian general practitioners 132 responded to a questionnaire survey. MAIN FINDINGS: Diuretics are the most commonly chosen drug for the initial management of uncomplicated moderate hypertension. Equivalent patients aged 45, 60 and 75 years would be prescribed a diuretic as drug of first choice in 41%, 55% and 68% of cases respectively. Despite this, there are wide differences in the choice of initial therapy between individual practitioners. These differences can have a substantial cost impact, given that in Australia the cost of diuretic therapy for one month can be as low as $1.97 compared with $34.08 for standard angiotensin converting enzyme inhibitor therapy for one month. There was also a perceived need, and demand, for patient education materials to assist practitioners in the drug treatment of hypertension.

The sprained ankle. Diagnosis and management of lateral ligament injuries.

Ankle sprains are common injuries. They are often associated with residual disability with the ankle tending to give way on uneven ground (functional instability). Good management and rehabilitation require accurate diagnosis of the nature and extent of the injury, attention to the physical treatment and follow up with ankle strengthening and proprioceptive exercises to minimise the risk of functional instability.

South Australian hypertension survey. General practitioner knowledge and reported management practices--a cause for concern?

OBJECTIVE: To survey South Australian general practitioners to investigate their knowledge and reported management of patients with hypertension. DESIGN, SETTING AND PARTICIPANTS: Of 156 randomly selected SA general practitioners 132 responded to a questionnaire survey. RESULTS: This survey showed substantial differences between general practitioners in their knowledge about hypertension and in their reported practices for diagnostic levels, investigations to be undertaken once diagnosis had been made, levels at which pharmaceutical treatment should be initiated, at which level treatment was regarded as having attained satisfactory control, and length of time for routine review. There was also a demand for materials to be provided to assist in the management of this important condition. CONCLUSIONS: There is a perceived need for better and more appropriate educational materials and a need for a different approach to try and reduce the reported variability in management of patients with hypertension by general practitioners.

Drug and alcohol related health problems in primary care--what do GPs think?

OBJECTIVE: To examine knowledge, attitudes and beliefs of general practitioners (GPs) in the field of drug and alcohol related health problems. DESIGN: A cross-sectional survey in which self-completion postal questionnaires were sent to all identifiable GPs in the Adelaide metropolitan area. Non-responders received a reminder letter and second questionnaire. SETTING, PARTICIPANTS: The target population was doctors whose principal activity was general practice, or who were in training for general practice. MAIN OUTCOME MEASURES: Demographic and "practice characteristic" information on participants. Measures of knowledge, attitudes and beliefs regarding alcohol consumption, smoking and over the counter medication. RESULTS: The response rate was 59.8%. More responders than non-responders were affiliated with the Royal Australian College of General Practitioners. Alcohol consumption was perceived to be a more difficult issue than smoking to raise during consultations. GPs indicated that significant proportions of their patients were participating in hazardous drinking (mean estimate was 13.8% of patients), but only a third of respondents believed their effort in changing alcohol related behaviour would be effective. Sixty-one per cent of respondents identified hazardous daily levels of alcohol consumption for men consistent with National Health and Medical Research Council guidelines. In the case of women this figure was 42%. Longer reported appointment times were associated with greater reported levels of enquiry about alcohol consumption. CONCLUSIONS: New developments in medical training and systems of payment in general practice need to address both the pessimistic attitude of GPs in dealing with drug and alcohol related health problems, and apparent inconsistencies in defining hazardous alcohol consumption.