Quality and equity in cancer care : how can we be sure?

Cancer research from the bench, to the bedside and beyond continues to make major strides leading to decreased mortality, an increased number of survivors and improved quality of life. What is less apparent is how well these research findings are translated into high quality equitable, evidence-based care and an effective, acceptable mechanism for monitoring care. Australian cancer health professionals are among the world’s best; helping to save lives, promote good health, prevent disease and improve quality of life. Whilst this suggests that evidence-based health care and quality management have been generally adopted there are noticeable areas of concern, especially around access to and continuity of care. For over two decades, the influence of the social determinants of health has been known, not just on health status and survival, but also on treatment patterns. Health systems that pride themselves on universality should be concerned if people are being effectively discriminated against due to location, socio-economic, financial or racial factors. From a research, policy and practice perspective, it is not enough to know what works for the average patient with the average specialist, but who receives what treatment, where, when and why and, importantly, why not

The quality management and health promotion practice nexus

As health promotion has developed, there has emerged a range of underlying concepts, principles and practices which have been integrated into best practice. This includes ethical principles (such as beneficence and autonomy), the concepts of social justice, equity, advocacy, empowerment, social capital, and practices such as consumer participation, capacity building, the use of process, impact and outcome evaluation and evidenced-based practice. These create a unique philosophical and operating platform, from which health promotion initiatives should derive many of their operating procedures. In recent years another concept, that of quality management has been introduced into health promotion practice. The introduction of quality management has the capacity to enhance work practice if done in a way that is sympathetic to these existing principles, concepts and philosophies. This paper provides an overview of quality management and discusses the potential benefits it could bring to health promotion practice. Quality management with its support for a flatter management structure and attention to staff experience and needs, offers a system that could enhance training and service delivery via the creation and introduction of checklists, benchmarks and other quality management processes. The quality management construct of internal and external customers could enhance health promotion practice via its explicit identification of, “customer” needs and the meeting of these needs. The paper identifies a strong nexus between existing health promotion practice and quality management, however it also concludes that as the quality management paradigm does not contain the constructs of social justice, equity or empowerment and as these are central to health promotion practice they need to be embedded into any quality management approach before it is imposed onto health promotion activity. Quality management offers health promotion practitioners the opportunity to operationalise these concepts, principles and practices into every day activity; to take what is implicit in the major trends identified in health promotion and make them an explicit part of practice

A prospective study of the costs of falls in older adults living in the community

Objective: To establish the hospital cost and three-month, post-hospital community and personal costs associated with older adults discharged to the community after a fall. The timing, incidence and the determinants of these costs to the various sectors were also examined. Methods: Patients who attended the Emergency Department of a teaching hospital in Perth, Western Australia, were asked to complete a daily diary for three months of all community and informal care they received due to their fall and any associated expenses. Unit costs were collected from various sources and used to estimate the cost of community and informal care. Hospital inpatient costs were estimated using a patient-based costing system. Results: Seventy-nine patients participated with a total estimated falls-related cost for the three-month period of $316,155 to$333,648 (depending on assumptions used) and a mean cost per patient of between $4,291 and$4,642. The hospital cost accounted for 80%, community costs 16% and personal costs 4% of the total. Of community and personal costs, 60% was spent in the first month. Type of injury was the most significant determinant of hospital and community costs. Extrapolating these figures to the WA population provided an estimate of the total hospital and three-month, post-hospital cost of falls of $24.12 million per year, with$12.1 million funded by the Federal Government, $10.1 million by State/local government and$1.7 million in out-of pocket expenses by patients. Conclusion: In the acute and immediate post-discharge period, hospital costs accounted for most of the cost of care for older adults discharged to the community after a fall. Community and personal costs, however, were also incurred. The cost estimates provide useful information for planners of hospital and community care for older people who have sustained a fall

Bridging the gap: Integrating quality management into health promotion practice

In the 1940's, the business world saw a move towards the use of quality management to ensure the quality and consistency of the product for the customer. By the 1980's, quality paradigms had started to infiltrate the health system in an attempt to reduce clinical errors and improve patient satisfaction

Is hostel care good for you? Quality of life measures in older people moving into residential care

Objectives: For many older adults, moving into hostel accommodation can be a stressful and traumatic process. The impact of this move on the quality of life and function after a three month adjustment period was evaluated in this study. Method: A Folstein Mini Mental State Examination (MMSE), Modified Barthel Index (MBI), Short Form 36 (SF-36) and demographic information was collected prior to entry to hostel accommodation. The SF-36 was repeated three months after admission. The SF-36 has eight domains: physical functioning, role physical, bodily pain, role emotional, mental health, vitality, general health, and social functioning. Results: Fifty subjects met the inclusion criteria and moved into hostel accommodation during the study period. The MMSE had a mean ± sd 26.6± 3.29 (highest cognition score = 30) and the MBI 93.4 ± 5.71 (highest level of independence score = 100), with no gender or age effect. The SF-36 improved in 7/8 domains (p<0.05) after admission to hostel, with only mental health not improving significantly. Despite improving, physical functioning remained below the age and gender matched Australian norm for the SF-36 in both males and females aged over 75. For women there also continued to be a reduction in social function, general health and mental health. Conclusions: This study showed that both men and women had an overall increase in their quality of Life after admission to hostel care. A comparison of our group to the Australian age and gender matched norms for quality of life illustrated that for many in our group their quality of life compared favourably to people living in the community, and that moving into hostel accommodation had been shown to be a valuable option

The influence of socio-economic and locational disadvantage on patterns of surgical care for lung cancer in Western Australia 1982-2001

Objective: Patterns of in-hospital surgical care for lung cancer in Western Australia were examined, including the effects of demographic, locational and socio-economic disadvantage and the possession of private health insurance, on the likelihood of receiving surgery. Patients and methods: The WA Record Linkage Project was used to extract hospital morbidity, cancer and death records of all people with lung cancer in Western Australia from 1982 to 2001. The likelihood of receiving lung cancer surgery was estimated, after adjustment for co-variates, using logistic regression. Results: Overall, 16... of patients received surgery for their lung cancer, although this varied according to histology. Patients who received surgery were typically younger, female, non-indigenous and had less comorbidity. Patients from socio-economically disadvantaged groups tended to be less likely to receive surgery (OR 0.79; 95% CI 0.61-1.04) although this was not significant for each category of disadvantage. Those who had their first hospital admission, with a mention of lung cancer, in a rural hospital were less likely to receive surgery (OR 0.26; 95% CI 0.19-0.36) than those in metropolitan hospitals, although residential location generally had less effect (OR 0.36; 95% CI 0.14-0.92). Patients admitted as a private patient either to a private or public hospital for their first mention of lung cancer had increased likelihood of receiving surgery (OR 1.15; 95% CI 1.02-1.30); however first admission to a private hospital had no effect (OR 0.99: 95% CI 0.85-1.16). Conclusion: The utilisation of lung cancer surgery was low with several factors found to affect the rate. Patients from socio-economically or locationally disadvantaged backgrounds, indigenous patients or patients without private health insurance were less likely to receive lung cancer surgery than those from more advantaged groups

A prospective study of falls following hip fracture in community dwelling older adults

Objectives. This cohort study was designed to determine if the rate of falls, subsequent injuries and the utilisation of health and community care services was higher over one year in a group of community living hip fracture subjects (six-twelve months post fracture) than in age and gender matched controls. Functional and quality of life measures were assessed as potential predictors of falls. Method. 92 age (mean age 76) and gender (60 females: 32 males) matched subjects had demographic, functional and quality of life measures assessed at baseline. Over the following year datlrm on the number of falls, trips and stumbles and the circirmstances surrounding the event were collected by monthly telephone surveillance. Results. The incidence rate for both falls and events, including where the event occurred, were similar for the groups. The distribution of the type af event was different with the fracture group experiencing more falls and stumbles and the controls more trips. The fracture group had more significant injuries, including fractures, and was more likely to have sought medical attention. The Berg Balance Scale, Frenchay Activities of Daily Living and the physical function domuin of the SF-36 were negatively predictive of falls. Conclusions. The hip fracture patient, living in the community 6-12 months later, is no more likely to fall than their age and gender counterpart, however, they presented with a different and more severe pattern of injury and an increased use of GP services. The fracture group was also noted to be less active, indicating that they may have made lifestyle modifications, which may decrease their risk of falls

A case-control study of quality of lie and functional impairment in women with long-standing vertebral osteoporotic fracture

There have been several studies of the impact of vertebral osteoporotic fracture on the quality of life and functionality of individual subjects. To date, however, no direct comparisons with age-matched normal subjects without vertebral fracture have been made. The radiographs of 145 female clinic patients with vertebral fractures were reviewed by the study physicians. The controls were recruited from the electoral role and by media appeal. One hundred and sixty-seven women had radiographs taken to determine those without vertebral fracture. Fracture subjects and controls had to be ambulant and were excluded if they had significant radiologic evidence of degenerative disk or joint disease of the spine. One hundred cases and one hundred controls were matched by 5-year age groups. The number, position and severity of the vertebral fracture on the lateral radiographs of the cases was recorded. Quality of life was measured using the Short Form-36 (SF-36) (maximum score 100) and a utility score calculated from thesese results (maximum score 1). Two measurements of functionality were employed: the Modified Barthel Index (MBI) to assess the activities of daily living (maximum score 100) and the Timed 'Up & Go' (TUG) that measured the time taken for the subject to rise from sitting in a chair, walk 3 m along a line, return to the chair and sit down. The fracture subjects had 2.9 ± 1.6 (mean ± SD) vertebral fractures and the time since last fracture was 5.1 ± 4.8 years. The SF-36 physical function component summary index results were: fracture subjects 36 ± 11, controls 48 ± 9 (p < 0.001). The SF-36 mental health component summary index results were: fracture subjects 50 ± 11, controls 54 ± 8 (p <0.05). The utility scores were: fracture subjects 0.64 ± 0.08, controls 0.72 ± 0.07 (p <0.001). The MBI results were: fracture subjects 97 ± 5, controls 99 ± 1 (p< 0.01). The TUG results were: fracture subjects 13.8 ± 7.3 s, controls 10.1 ± 4.1 s (p <0.01). TUG and MBI scores correlated well with SF-36 scores; however, no domain of the SF-36 or functional measure correlated with either the number of vertebral fractures or the time since last vertebral fracture. Thus, clinically reported vertebral fractures impair both the quality of life and functionality of these subjects. The adverse impact of vertebral fracture on quality of life and functionality needs to be recognized by medical practitioners, subjects and the community, so that adequate health resources can be devoted to the prevention and treatment of this debilitating condition condition

Health system costs of falls of older adults in Western Australia

The aim of this study was to determine the health system costs associated with falls in older adults who had attended an emergency department (ED) in Western Australia. The data relating to the ED presentations and hospital admissions were obtained from population-based hospital administrative records for 2001-2002. The type of other health services (eg, outpatient, medical, community, ancillary and residential care), the quantity, and their cost were estimated from the literature. In adults aged 65 years and above, there were18 706 ED presentations and 6222 hospital admissions for fall-related injuries. The estimated cost of falls to the health system was $86.4 million, with more than half of this attributable to hospital inpatient treatment. Assuming the current rate of falls remains constant for each age group and gender, the projected health system costs of falls in older adults will increase to$181 million in 2021 (expressed in 2001-02 Australian dollars). The economic burden to the health services imposed by falls in older adults is substantial, and a long-term strategic approach to falls prevention needs to be adopted. Policy in this area should be targeted at both reducing the current rate of falls through preventing injury in people from high-risk groups and reducing the future rate of falls through reducing population risk

Unequal access to breast-conserving surgery in Western Australia 1982-2000

Background: The purpose of the present study was to examine the effects of demographic, locational and social disadvantage and the possession of private health insurance in Western Australia on the likelihood of women with breast cancer receiving breast-conserving surgery rather than mastectomy. Methods: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2000 inclusive. Comparisons between those receiving breast-conserving surgery and mastectomy were made after adjustment for covariates in logistic regression. Results: Younger women, especially those aged less than 60 years, and those with less comorbidity were more likely to receive breast-conserving surgery (BCS). In lower socio-economic groups, women were less likely to receive BCS (OR 0.73; 95% CI 0.60-0.90). Women resident in rural areas tended to receive less BCS than those from metropolitan areas (OR 0.84; 95% CI 0.55-1.29). Women treated in a rural hospital had a reduced likelihood of BCS (OR 0.74; 95% CI 0.61-0.89). Treatment in a private hospital reduced the likelihood of BCS (OR 0.70; 95% CI 0.54-0.90), while women with private health insurance were much more likely to receive BCS (OR 1.39; 95% CI 1.08-1.79). Conclusion: Several factors were found to affect the likelihood of women with breast cancer receiving breast-conserving surgery, in particular, women from disadvantaged backgrounds were significantly less likely to receive breast-conserving surgery than those from more privileged groups