But, says Adjunct Professor Debora Picone AO, CEO of the Australian Commission on Safety and Quality in Health Care, much work remains.
Commenting after the launch of Australia’s Fourth Australian Atlas of Healthcare Variation, Professor Picone says the series continues to provide compelling findings that ‘we must act on’.
This Atlas reveals that, across Australia, 42.8%–56.1% of all caesarean sections performed before 39 weeks did not have a medical or obstetric indication for early birth. This is despite strong evidence that waiting until at least 39 weeks’ gestation gives better short- and long-term outcomes for the baby, unless there are medical or obstetric reasons for earlier birth. The research shows that the last few weeks of pregnancy are important for the baby’s development, including brain and lung maturation.
Commission Chair Professor Villis Marshall AC says that it is more important than ever to have a strategic approach to healthcare variation.
‘Although the [COVID-19] pandemic has dominated the health news and placed extra demands on the system, the longstanding challenges we face in health have not gone away.’
What is variation?
The Commission describes variation as a ‘difference in healthcare processes or outcomes, compared to peers or to a gold standard such as an evidence-based guideline recommendation’.
Professor Anne Duggan, the Commission’s Clinical Director, says that healthcare variation can be the ‘hallmark of a sophisticated healthcare system’, reflecting different patient needs or preferences.
But variation can also be a sign that suboptimal care is being provided or that access to health care is inequitable.
Such unwarranted variation may relate to: the health system (ineffectiveness, inefficiencies or indication creep); clinicians (distribution, skill or adherence to the latest evidence); and consumers (too little or too much access to care, financial/geographic barriers, understanding of risks/benefits, and lack of opportunity to participate in decision-making).
Home truths
Australia’s participation in a 2012 Organisation for Economic Co-operation and Development (OECD) study on international healthcare variation revealed some concerning facts about the appropriateness of care delivery, Professor Picone says.
‘Australia had a higher hysterectomy rate than any other OECD country, and there was no reason for that,’ she says. The study showed that Australia’s hysterectomy rate was 230 per 100,000 women, compared with 178 in New Zealand, and 149 in England.
‘This suggested that hysterectomy was being used as the first treatment option for menorrhagia, in particular, and in menopause,’ she says, noting that this is not in line with the evidence encouraging the first-line use of less invasive approaches.
Australia’s caesarean section and tonsillectomy rates were also found to be far higher than those of comparable nations.
These findings prompted the Commission to develop the Atlas series to examine healthcare variation across Australia and to map findings by geographical region. The first Atlas was launched in 2015.
Success stories
Despite mounting evidence of a lack of benefit, arthroscopy rates for knee osteoarthritis skyrocketed in the early 2000s.
The 2012 OECD study found that Australia was again towards the top of the table in the rate of knee arthroscopies performed. And the first Atlas reported not only high rates of knee arthroscopy, but also considerable variation across the country.
‘South Australia had the highest intervention rates overall,’ Professor Picone says. ‘Rates in some areas of South Australia were seven times higher than areas in NSW and the ACT with the lowest rates.’
To tackle this unwarranted variation, the Commission provided this data to local health services and governments. Then, in 2017, the Commission supported clinicians to provide evidence-based care with the release of a Clinical Care Standard for managing knee osteoarthritis.
In 2018, the Commonwealth Government revised the Medicare Benefits Scheme item numbers for the procedure. At the same time, research and guidelines highlighting the lack of benefit of knee arthroscopy for osteoarthritis helped to drive rates down.
Seven years later, Australia’s rate of knee arthroscopies had halved from 512 knee arthroscopies per 100,000 people in 2012, to 247 per 100,000, in 2019.
Initiatives across the health system to reduce the use of hysterectomy have also been effective, Professor Picone says, with particularly impressive results in Victoria.
In 2014-15, Victoria had a hysterectomy rate of 281 per 100,000, and a Commission analysis of data from the National Hospital Morbidity Database 2014-15 and 2018-19, shows that rate had now dropped to 236 per 100,000.
The key to the Commission’s successes in tackling healthcare variation is the engagement and commitment of expert clinicians, Professor Picone says.
‘We work with a group of experts who are on the frontlines every day of the week dealing with these issues,’ she says. ‘We bring the evidence and the data, and we share examples of better practice. We challenge the status quo thinking.’
Engaging consumers in the process by encouraging informed consent is also crucial in tackling unwarranted variation, she says.
Work in progress
It’s not all good news though. Professor Picone says Australia continues to have one of the world’s highest rates of antibiotic prescribing, and the rate of early planned caesarean sections (before 39 weeks, without medical or obstetric indication) remains unacceptably high.
Equitable access to care in rural regions and for remote Aboriginal and Torres Strait Islander communities continues to be a major challenges for the nation, she says.
Professor Picone says the Commission will carry on with its work in these areas, acknowledging that some areas of unwarranted healthcare variation cannot be changed overnight.