It’s an unsettling statistic, and despite huge efforts within the health sector to address patient safety, the ‘adverse events in hospital’ number has remained the same for the last quarter of a century.
Frozen: The number of patients harmed while in hospital has remained unchanged for a quarter of a century, Braithwaite says.
“Healthcare is frozen, statistically, in time,” says Professor Jeffrey Braithwaite, who heads the Centre for Healthcare Resilience and Implementation Science at the Australian Institute of Health Innovation at Macquarie and has been researching health systems for decades.
“Despite enormous efforts to improve healthcare quality, we’ve got systems performance measurements that have stagnated,” he says. “For example, around 50-60% of care is delivered in line with evidence-based guidelines – and that statistic has been the same for at least a decade and a half.”
He cites two other intractable key health indicators. “Around a third of medicine is waste, with no measurable effects or justification for the considerable expenditure, and the rate of adverse events across healthcare has remained at about one in 10 patients for 25 years.”
Quality in healthcare is a global issue, says Professor Braithwaite, who consults to the World Health Organisation and is President-Elect of the International Society for Quality in Health Care (ISQua) which co-ordinates a network of over 190 countries.
Making the trade-off
Despite stubborn statistics, Professor Braithwaite remains positive about the remarkable advances that have occurred in healthcare in recent decades.
“The system that delivers care is extremely complex and the average age of patients in hospital is around 65, many with multifaceted and chronic conditions,” he says.
Australia’s health system is a vast and complex machine, responsible for around ten percent of national GDP, costing over $200 billion a year, and employing around one in eight working Australians.
“The holy grail is: can we get care delivered to the right person at the right time, the right dose at the right price in the right setting,” says Professor Braithwaite. “It seems an almost impossible task when you consider the complexity and magnitude of our health system – and that those headline numbers have barely shifted over the last 25 years.”
But, he points out, that doesn’t mean we have a system that's totally broken.
“Most patients, most of the time, often with complex conditions and under complex circumstances get very good care,” he explains.
“If you look at these numbers from the other end of the telescope: nine in ten hospital visits are free from adverse events, even minor ones; 70 percent of medicine is not wasteful, and around 60 percent of care is entirely in line with evidence-based guidelines.”
Delivering the changes required to shift the headline figures will involve concerted effort, he says.
“It’s partly about trade-off; are we willing to pay 18 percent of GDP to make hospitals safer for every patient?”
Calibrating the health system
Bad combination: health budgets need to be reallocated to tackle the problems of under and overservicing patients in hospital, according to Braithwaite.
Many of the adverse events that make up the ‘1 in 10’ ratio are fairly minor, Professor Braithwaite says. “For example, someone might get 4mg instead of 5mg of a certain drug when they're in hospital; or perhaps they missed one dose of a medication in the drug rounds. There may be no harm registered, but it’s still necessary to report an adverse event,” he says.
The system can be made more effective and efficient by diverting resources away from unnecessary interventions and therefore risk, he says. “For most back pain, some analgesics, some watchful waiting and a bit of physio delivers the best long-term result, for example,” he says.
“But a proportion of patients will have their GP refer them to an orthopaedic surgeon and there's a chance that they'll then find themselves having an operation,” he says. “Some of those patients will be elderly, and the risks and the painful recovery involved is actually worse than the initial symptom.”
He says that not all healthcare issues are about unnecessary care; there’s many instances of under-servicing which could prevent harmful outcomes.
“For example, while lots of people have asthma, and regularly use a puffer, only about 20 percent have an asthma action plan which covers how to manage asthma across time,” he says.
“Yet the clinical guideline says that everybody with asthma should have a plan and should be following that up.” Many children grow out of asthma but continue taking a puffer throughout adulthood, and for many adults, their asthma treatment needs change over time, he says; both under- and over- treatment are problematic.
“It’s about avoiding both under- and over-servicing. We need to calibrate the health system so everybody gets exactly the right care at the right time in the right place by the right clinician.”
“In our healthcare system today, we’re doing things that are revolutionary,” says Professor Braithwaite. “We now perform low-impact procedures and keyhole surgery. We can safely do complex surgery on 70-year olds that we wouldn't have even attempted on healthy 40-year olds, 25 years ago,” he says.
“It is more likely today, that if you get cancer, you will survive it – whereas previously, you were far more likely to die from it.”
Our health system has gone through a skyrocketing trajectory to deliver complex and comprehensive care, all the while holding constant the statistics of waste, adverse events and care following guidelines, while so much more is being done for patients, he says.
Despite this, he says, no-one in health is willing to accept that the three headline figures are ‘ground zero’ for healthcare.
He says that the next step is to whittle down the frozen statistics bit by bit by bit, using the very latest in monitoring patient care, harnessing big data, capturing eHealth intel, and mobilising communication from patients and health workers into ‘feedback loops.’
“From involving patients far more in studies, to getting the clinical teams on the frontlines of care driving change rather than just complying with more policy, our next step must be more sophisticated in the way we do change and improvement.”