Launched last month, the Australian Commission on Safety and Quality in Health Care’s Fourth Australian Atlas of Healthcare Variation (the Atlas) covers 17 healthcare items across six clinical areas.
These are: potentially preventable hospitalisations; early planned birth; lumbar spinal surgery; ear, nose and throat surgery in children and young people; gastrointestinal investigations; and medicines use in older people.
Potentially preventable hospitalisations
The Atlas reports that in 2017-18 there were more than 330,000 PPHs in Australia due to five conditions examined in the Atlas. PPHs – hospitalisations that could have been avoided with earlier, appropriate care – are an indicator in the National Healthcare Agreement.
Some of the most common reasons for a PPH include three chronic conditions and two common infections: chronic obstructive pulmonary disease (COPD), kidney infections and urinary tract infections, cellulitis, heart failure, and diabetes complications.
After age and sex standardisation, the Atlas reports wide variation in hospitalisation rates nationally for the five conditions, including an 18-fold difference for COPD between the area with the lowest rate and the area with the highest rate, a 16-fold difference for cellulitis, and a 12-fold difference for diabetes complications (See Box).
For all the conditions examined, hospitalisation rates were higher among Aboriginal and Torres Strait Islander peoples, people living in areas of socioeconomic disadvantage, and those living in remote areas.
In addition to efforts to improve access to care, the Atlas recommended ‘a fundamental shift’ to direct healthcare investment towards a better integrated primary care system.
Funding solutions
Mr James Downie, CEO of the Independent Hospital Pricing Authority, says innovative funding models may be part of the solution to PPHs.
He notes that traditional activity-based funding models provide limited incentive for hospitals to prevent re-admission.
‘We think alternative approaches to funding for chronic disease have a lot of potential,’ he says, adding that one type of funding model provides the hospital (fundholder) with a budget for a defined period to manage all elements of care for specific types of chronic conditions.
Capitation funding, bundled payments or regionally coordinated service responses Mr Downie says, can help to integrate care across the primary, secondary and hospital sectors.
‘Hospital admissions are very expensive, so if we can prevent one admission, it frees up a lot of money to be spent on prevention and other out-of-hospital care,’ he says.
Mixed results
One capitation funding model, HealthLinks, is currently being trialled in Victoria. Four health services (Alfred, Barwon, Monash, and Western Health) are participating in the HealthLinks program, which started in 2016-17.
The program involves identifying people with chronic and complex health conditions who are at high risk of three or more unplanned hospital admissions in a 12-month period. These patients are then provided with additional support services – such as telephone coaching and post-discharge follow up – to prevent hospital readmission.
Mr Downie says the program has shown some ‘promising signs’, but overall, the results have been mixed.
A recent Productivity Commission report shows that although the services all reported positive results, including better patient outcomes and more efficient hospital use, the program did not reduce admissions or length of stay.
Mr Downie notes, however, that it’s still relatively early days for the HealthLinks program.
‘It does take a long time to get these new approaches to bed down,’ he says. ‘But it's not providing overnight results.’
Mr Downie says further funding reform models would be investigated as part of the new Health Reform Agreement.
GPs ‘conductors’ of care
Professor Anne Duggan, the Commission’s Clinical Director, says lifestyle factors are at the core of many of the conditions driving Australia’s high rate of PPHs.
‘We are not going to fix potentially preventable hospitalisations by being at the end of the journey,’ she says. ‘We will have to tackle the problem early on.’
Professor Duggan says it’s ‘incredibly important’ for people to be connected to a GP who can be at the centre of their care.
‘The best care comes from the GP,’ she says. ‘The GP should be the conductor of the orchestra. They can get advice from a consultant when specific advice is needed, co-ordinate care and support patients to self-manage,’ she says.
Access to care
Professor Duggan says workforce maldistribution is a further factor contributing to Australia’s rate of PPHs.
‘There is a huge workforce shortage in rural and remote areas, not only of doctors but of allied health professionals,’ she says. ‘If you have diabetes, you need a whole lot of allied health support — you need a podiatrist, the dietitian, you need an optometrist.’
And social determinants of health such as nutrition and housing also play a role in the repeated hospitalisations for conditions such as cellulitis.
‘Part of the cellulitis story is related to where you live; the climate of where you live, your level of nutrition; your housing situation – is it crowded? Does it have hot water?’ Professor Duggan says. ‘And if you don’t have access to a GP, you are going to have high rates of cellulitis.’
Fourth Atlas: PPHs snapshot COPD
- 77,754 hospitalisations for COPD, representing 260 hospitalisations per 100,000 people of all ages (2017–18,).
- Across 328 local areas (Statistical Area Level 3) COPD hospitalisations ranged from 56 to 1,013 per 100,000 people – an 18.1-fold variation.
- The rate of COPD hospitalisations per 100,000 people nationally increased by 8% between 2014-15 and 2017–18.
Cellulitis
- 68,663 hospitalisations for cellulitis, representing 256 hospitalisations per 100,000 people of all ages (2017–18).
- Across local areas, cellulitis hospitalisations ranged from 90 to 1,393 per 100,000 people – a 15.5-fold variation.
- Hospitalisations nationally increased by 9% (between 2014–15 and 2017–18) while for Aboriginal and Torres Strait Islander people the rate increased by 18%.
Diabetes complications
- 50,273 hospitalisations for diabetes complications, representing 184 hospitalisations per 100,000 people of all ages (2017–18).
- Across local areas, diabetes complications ranged from 64 to 782 per 100,000 people -- a 12.2 times variation.
- Diabetes hospitalisations increased by 7% nationally (between 2014–15 and 2017–18).
Kidney and urinary tract infections
- 76,854 hospitalisations for kidney infections and UTIs, representing 281 hospitalisations per 100,000 people of all ages (2017–18).
- Across local areas, the hospitalisation rate for kidney infections and UTIs ranged from 141 to 893 per 100,000 people – a 6.3-fold variation.
Heart failure
- 62,554 hospitalisations for heart failure, representing 201 hospitalisations per 100,000 people of all ages (2017–18).
- Across local areas, the hospitalisation rate for heart failure ranged from 91 to 531 per 100,000 people – a 5.8-fold variation.