Technology and Clinicians

Rob Buist, National Women’s Hospital, Auckland, Scott MacFarlane, Starship Children’s Hospital, Auckland, and Anne Cahill, Women’s Hospitals Australasia & Children’s Hospitals Australasia, Canberra, Australia, co-presented this paper focused on technology and clinicians.

Anne Cahill opened by listing hospitals that are members of Women’s Hospitals Australasia and Children’s Hospitals Australasia, highlighting the New Zealand hospitals (refer slides 2 and 3).

The presentation focused in particular on the role of benchmarking and the technology supporting this function.

Cahill reviewed the benchmarking approach used by the Women’s Hospitals Australasia and Children’s Hospitals Australasia. She noted that the software used currently for analysis of member hospitals’ activities, located in each member hospital, is a little cumbersome but that the organisations intend to move to a web-based system. The current system collects and allows peer-based comparison of clinical costing and activity. A key feature is the ability to look across jurisdictions and compare, eg, Starship Children’s Hospital, Auckland, and The Children’s Hospital at Westmead, Sydney. A commonly agreed set of standards is applied so that data are managed in the same way, eg, standards concerning depreciation formulae.

The benchmarking system is intended to provide a decision support tool, not a management tool for criticising clinicians.

In addition, ad hoc data are collected on obstetrics and clinical indicators. These data will be drawn together in the web-based version of the system.

Cahill described the "Clinical Forum Program" through which member hospitals select topics and a clinical reference group is formed which identifies the questions for examination and the data sources, including surveying members. The clinical forum brings together clinicians across Australasia to identify best practice, work to be undertaken, etc.

Rob Buist discussed the Caesarean Section, Asthma and Perioperative Forums

He described the Caesarean Section Forum as a multi-disciplinary group comprising midwives, managers and obstetricians that worked together to consider the issue of the increasing caesarean section rate. The forum worked on key questions in attempting to breakdown a very complex topic.

The first meeting of the Caesarean Section Forum in March 2001 involved a representative of each of the member hospitals and the RANZCOG (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists), a consumer representative, an epidemiologist and a lawyer. All hospitals produced data related to caesarean sections. The forum identified that caesarean sections are performed in response to several different situations and the discussion was therefore broken down into several separate areas for consideration by different groups:

Despite an ongoing concern with cost of caesarean section, it was noted that caesarean section is not necessarily more expensive than vaginal delivery (refer slide 10) .

A similar strategy was used to set up the Asthma Forum, which asked two basic questions about asthma:
   • What can we do to keep children with asthma out of hospital?
   • If admitted, how can we reduce the length of hospital stays for asthmatic children?

Buist presented graphs relating to the top 10 Diagnostic Related Groups (DRGs) in Children’s Hospitals Australasia (refer slide 15). The graphs showed examples of the ways that data which are collected can be used to benchmark between peer organisations. Findings included, for example, that data from different member hospitals showed a substantial variation in practice between same-day and overnight procedures in these hospitals (refer slide 16).

Another example showed expenditure in different costing groups for different member hospitals (refer slide 21).

Anne Cahill presented similar examples of the use of data for the top 10 DRGs in the Women’s Hospitals Australasia. One example showed the proportions of same day and overnight separations for all discharges across the different member hospitals (refer slide 23). A second example allowed comparison of average length of stay for vaginal delivery without complicating diagnosis across different member hospitals for 1999/2000 and 2000/2001 (refer slide 24) and associated changes in average costs (refer slide 25).

Rob Buist presented data on caesarean section rates across member hospitals (refer slide 27). He noted that the number of members in the Women’s Hospitals Australasia allows stratification of hospitals, eg, by tertiary hospital. Data on caesarean section rates could be used for ad hoc benchmarking and to guide decision-making for the Caesarean Section Forum. The process highlights those member hospitals whose results are outliers, allowing these organisations to identify and work on possible issues. He also presented data across member hospitals on rates of vaginal birth after caesarean section and on neonatal death rates (refer slides 28 and 29). He noted that data on neonatal death rates could be used by the relevant member hospitals to determine whether there is a data collection issue, a reporting issue or a real clinical issue resulting in higher neonatal death rates.

Scott MacFarlane discussed the use of high-cost technologies. He opened by reviewing some of the many reasons why hospitals offer high-cost technology treatments including their role as "magnets for referrals" and their positive effect on staff recruitment and retention. He noted that their provision might be clinically sensible for achieving critical patient numbers and staff cover and experience. However, he also noted that high cost technologies can too often be responsible for significant losses. High-cost technologies have a high impact on the individual patient and family but little impact on the health of the population and therefore attract rationing questions.

MacFarlane considered three high-cost interventions and compared them to the revenue they create. He showed the losses resulting from admissions involving PICU (paediatric intensive care unit) care at Starship Children’s Hospital (refer slide 34), noting that losses were higher on admissions from outside the Auckland DHB. He noted that patients admitted from outside Auckland will be sicker, thus the complexity/cost curve gets shifted to the right (refer slide 35). However, he noted that providing such services defines the "tertiary-ness" of a hospital and they are needed to ensure that there is a critical mass of patients. He presented data on financial losses from admissions with tracheostomy (refer slide 36) and paediatric oncology (refer slide 37). He presented data on profits and losses from liver transplants (refer slide 38), noting that the hope is that the mix of profitable, uncomplicated and clinically typical cases and highly unprofitable, complex cases will end up being cost neutral.

MacFarlane then presented the price adjustment strategies available to Starship Children’s Hospital. The first is to raise the paediatric case price per DRG, recognising higher costs for paediatric as opposed to adult care (Children’s Hospitals Australasia has evidence showing 10-20% higher costs in each DRG). The second is to have a programme fee which recognises the availability/ infrastructure costs, eg, for providing liver transplants. The third is a tertiary adjuster, the equivalent of a base fee increase for complex patients. Fourth is a fee for service reflecting true cost recovery, for example for overseas patients. And the fifth is the use of "top ups" to WIES (Weighted Inlier Equivalent Separations) payments for costs of prostheses or materials acquisition, eg, a bone marrow donor fee to cover adult donor marrow procedure or cord blood bank unit recovery costs.

In summary, MacFarlane reiterated that high-cost technologies characterise tertiary specialty hospitals. The increasing range and cost of such interventions for individual patients is being questioned in a financially pressured environment where population health is considered very important. He noted that the hospital’s desire is to continue to provide these technologies for many good reasons and that the challenge is how to continue to do so.
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