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Showcasing research into sustainability of healthcare systems

Introduction by Croakey: On 16 June, the NHMRC Partnership Centre for Health System Sustainability (PCHSS), based at Macquarie University in Sydney, is hosting an event to celebrate the culmination of six years of research into improving the sustainability of healthcare systems.

As well as showcasing research outcomes and recommendations, there will be an interactive simulation of the healthcare system, inviting participants “to think outside the box” to explore solutions to ongoing challenges.

You can catch a sneak preview of the discussions from the post below, which includes a selection of tweets by @PCHSS_AIHI when recently guest tweeting for Croakey’s rotated, curated Twitter account, @WePublicHealth. Overdiagnosis, safety and quality, sustainability, telehealth and Learning Health Systems were among the topics covered.

Hosted by the Australian Institute of Health Innovation, the PCHSS is a collaborative research network of 17 lead investigators, 20 expert advisors, and over 40 system implementation partners from across the country.

(And follow @WePublicHealth this week to hear from the Healthy Environment and Lives (HEAL) Network.)


Tweets by PCHSS

This tweet refers to a study published in Annals of Internal Medicine in 2019, ‘Recognizing the Potential for Overdiagnosis: Are High-Sensitivity Cardiac Troponin Assays an Example?’

“Overdiagnosis occurs when persons are labelled with a technically correct diagnosis that does not improve health outcomes”, write PCHSS investigators Professor Paul Glasziou, Professor Rachelle Buchbinder, and colleagues.

The authors outline several questions that those responsible for establishing guidelines and policies ought to consider before recommending diagnostic procedures.

These include: whether such procedures will lead to increased diagnosis, whether any additional cases arising from new tests will be low risk, whether additional cases will receive treatment as a result of their diagnoses, and whether the potential harms of such treatments might outweigh the benefits.

The authors apply these questions to the subject of high-sensitivity cardiac troponin assays, highlighting a variety of potential downsides to the use of a test which, they state, became required or performed “before worldwide regulatory approval”.

They state:

Our analysis underscores the need to better evaluate new tests before integration into usual care. The benefits from new tests may be smaller than expected, and there may be unanticipated harms from overuse and overdiagnosis.”

This tweet refers to an article by Dr K-lynn Smith, Professor Yvonne Zurynski and Professor Jeffrey Braithwaite of PCHSS’s Observatory, published recently in a special climate-centred issue of The Journal of the American Medical Informatics Association (edited by PCHSS’s Professors Enrico Coiera and Farah Magrabi), in which they discussed the current informatic methods and tools available to assess this environmental impact of healthcare.

They highlight that the most accessible and complete data to assess climate impact is currently economic activity data, which can be used in tools such as multi-region input-output models to measure cross-flow transactions. This can then be linked to carbon emission data, or to life cycle assessments of greenhouse gas (GHG) contributions, to fully understand the entire environmental and economic impact of healthcare activity.

While tools like this are in practice, monitoring and reporting of data is fragmented, making it difficult to draw comparisons between healthcare networks, or to understand healthcare’s carbon impact on a broad level. For example, in Australia, the Australian Institute of Health and Welfare only reports aggregated country-level GHG data, rather than on a state-based level.

Overall, the tools and frameworks for measuring and monitoring environmental impacts of healthcare are developed and available, but data and information must be more readily captured and accessible if clinicians, researchers, and policy makers are to make a real difference to the threat of climate change.

Combined with high-level policies and a multisectoral approach, mitigating the effects of climate change might then be possible from a health system standpoint, as long as the data is there to support it. After all, we can’t mitigate what we don’t monitor.

A systematic review of digital health and climate change published by PCHSS researchers was also included in this issue; read more about it here.

Read more about the awards here.

This tweet refers to a paper from PCHSS researcher Professor Jeffrey Braithwaite and colleagues presenting the case for building the “Learning Health System 2.0” – an LHS that is increasingly better prepared for, and adaptive to, the pressures of future pandemics and climate change.

A Learning Health System (LHS) is a health system that combines science, informatics, culture, and incentives to produce high quality care, and continuous improvement and innovation in the health system.

The research team conducted a rapid review of the literature on six key themes to understand how healthcare organisations can be strategically enabled to become next generation Learning Health Systems.

The COVID-19 pandemic provided an opportunity for healthcare organisations to utilise LHS principles in their health setting, but few studies examined how the LHS could be used to prepare better for the next pandemic. No studies explored how the LHS could be used to assist healthcare organisations to prepare for the impact that climate change will have on human health and health systems.

The paper argues for health systems to use LHS frameworks, modelling and principles to manage the challenges presented by the current pandemic and the intensification of climate change, ultimately assisting those on the front lines of care to be future-proofed against pandemic- and climate-induced events as they unfold.

These guides answer questions like:

  • What are the benefits of telehealth?
  • When is a telehealth appointment appropriate?
  • What should I expect from my appointment?
  • How do I prepare and have my appointment?

This tweet links to a study published in BMJ Quality & Safety in August 2020, ‘Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients‘.

The researchers conducted a direct observational study of 298 nurses attending to over 1,500 patients. Observation was carried out by seven individuals with nursing or pharmacy qualifications that received extensive training that included workshops, simulated cases and infield practice.

Hospital policy stipulates double-checking for the administration of most medications, with only a select group – for example, oral antibiotics and vitamins, topical creams and ointments, laxatives, nasal drops, etc – not requiring independent double-checking. As such, across a total of 5,140 medication dose administrations, the observers found the majority (3,563) mandated double-checking.

Assessing all these cases of mandated double-checking, the researchers found no significant association between medication administration error and double-checking. The researchers point to the potential implications of their work for hospital policy. Citing other research with comparable outcomes, they note that “even when not compelled by policy, nurses will use their clinical judgement as to when a double-check may be warranted, and in such situations the process may be more likely to confer a benefit.”

Given the lack of a strong association between mandated double-checking and medication administration errors, they state that it may be time to reconsider this long-standing practice.

Healthcare systems are stuck in a rut. Despite countless reform efforts, the systems’ performance remains substantially the same: about 60 percent of care is in line with evidence-based guidelines, about 30 percent is wasteful or of low value to the patient, and about 10 percent is harmful. These numbers have not changed for decades.

In “The three numbers you need to know about healthcare: the 60-30-10 Challenge”, published in BMC Medicine in May 2020, PCHSS investigators Professor Jeffrey Braithwaite, Professor Paul Glasziou, and Professor Johanna Westbrook argue that health systems need to move away from top-down, linear models of change based on discrete interventions, and instead embrace the insights of complexity science to build virtuous cycles of continuous improvement.

They propose that a learning healthcare system, where knowledge generation is embedded in routine care practices, is a potential solution to this problem.

The authors conclude:

All modern health systems are awash with data, but it is only recently that we have been able to bring this together, operationalised, and turned into useful information by which to make more intelligent, timely decisions than in the past.”

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