Recommendations for and compliance with social restrictions during implementation of school closures in the early phase of the influenza A (H1N1) 2009 outbreak in Melbourne, Australia

Background

Localized reactive school and classroom closures were implemented as part of a suite of pandemic containment measures during the initial response to influenza A (H1N1) 2009 in Melbourne, Australia. Infected individuals, and those who had been in close contact with a case, were asked to stay in voluntary home quarantine and refrain from contact with visitors for seven days from the date of symptom onset or exposure to an infected person. Oseltamivir (Tamiflu^®) was available for treatment or prophylaxis.

Methods

We surveyed affected families through schools involved in the closures. Analyses of responses were descriptive. We characterized recommendations made to case and contact households and quantified adherence to guidelines and antiviral therapy.

Results

Of the 314 respondent households, 51 contained a confirmed case. The prescribed quarantine period ranged from 1-14 days, reflecting logistic difficulties in reactive implementation relative to the stated guidelines. Household-level compliance with the requirement to stay at home was high (84.5%, 95% CI 79.3,88.5) and contact with children outside the immediate family infrequent.

Conclusions

Levels of compliance with recommendations in our sample were high compared with other studies, likely due to heightened public awareness of a newly introduced virus of uncertain severity. The variability of reported recommendations highlighted the difficulties inherent in implementing a targeted reactive strategy, such as that employed in Melbourne, on a large scale during a public health emergency. This study emphasizes the need to understand how public health measures are implemented when seeking to evaluate their effectiveness.

Prevalence and characteristics of complaint-prone doctors in private practice in Victoria

OBJECTIVE

To identify characteristics of doctors who are repeated subjects of complaints by patients.

DESIGN AND SETTING

Case-control study of doctors about whom patients had complained to the Victorian Health Services Commissioner between 1 January 2000 and 31 December 2009.

PARTICIPANTS

384 doctors in private practice; cases comprised 96 doctors who were the subject of four or more separate complaints; and the control group comprised 288 doctors who were the subject of a single complaint over the study period.

RESULTS

Among doctors in private practice in Victoria, 20.5% (95% CI, 19.7%-21.3%) experienced at least one complaint over the decade. Among doctors who were the subject of a complaint, 4.5% (95% CI, 3.6%-5.4%) had four or more complaints, and this group accounted for 17.6% (95% CI, 16.3%-19.0%) of all complaints to the Victorian Health Services Commissioner. Multivariate analyses showed that surgeons (odds ratio [OR], 8.90; 95% CI, 3.69-21.50) and psychiatrists (OR, 4.59; 95% CI, 1.46-14.43) had higher odds of being in the complaint-prone group than general practitioners. Doctors trained overseas had lower odds of being complaint-prone than those trained in Australia (OR, 0.31; 95% CI, 0.13-0.72).

CONCLUSIONS

A small group of doctors in private practice in Victoria account for nearly 18% of complaints. Interventions to improve patient satisfaction and public confidence in health services should target complaint-prone subgroups of practitioners.

Doctors disciplined for professional misconduct in Australia and New Zealand, 2000-2009

OBJECTIVES

To describe professional discipline cases in Australia and New Zealand in which doctors were found guilty of professional misconduct, and to develop a typology for describing the misconduct.

DESIGN AND SETTING

A retrospective analysis of disciplinary cases adjudicated in five jurisdictions (New South Wales, Victoria, Queensland, Western Australia and New Zealand) in 2000-2009.

MAIN OUTCOME MEASURES

Characteristics of the cases (setting, misconduct type, patient outcomes, disciplinary measure imposed), characteristics of the doctors involved (sex, specialty, years since qualification) and population-level case rates (by doctor characteristics).

RESULTS

The tribunals studied disciplined 485 doctors. Male doctors were disciplined for misconduct at four times the rate of their female colleagues (91 versus 22 cases per 100 000 doctor-years). Obstetrics and gynaecology and psychiatry were the specialties with the highest rates (224 and 178 cases per 100 000 doctor-years). The mean age of disciplined doctors did not differ from that of the general doctor population. The most common types of offences considered as the primary issue were sexual misconduct (24% of cases), illegal or unethical prescribing (21%) and inappropriate medical care (20%). In 78% of cases, the tribunal made no mention of any patient having experienced physical or mental harm as a result of the misconduct. Penalties were severe, with 43% of cases resulting in removal from practice and 37% in restrictions on practice.

CONCLUSIONS

Disciplinary cases in Australia and New Zealand have features distinct from those studied internationally. The recent nationalisation of Australia's medical boards offers new possibilities for tracking and analysing disciplinary cases to improve the safety and quality of health care.

Administrative compensation for medical injuries: lessons from three foreign systems

The United States requires patients injured by medical negligence to seek compensation through lawsuits, an approach that has drawbacks related to fairness, cost, and impact on medical care. Several countries, including New Zealand, Sweden, and Denmark, have replaced litigation with administrative compensation systems for patients who experience an avoidable medical injury. Sometimes called "no-fault" systems, such schemes enable patients to file claims for compensation without using an attorney. A governmental or private adjudicating organization uses neutral medical experts to evaluate claims of injury and does not require patients to prove that health care providers were negligent in order to receive compensation. Information from claims is used to analyze opportunities for patient safety improvement. The systems have successfully limited liability costs while improving injured patients' access to compensation. American policymakers may find many of the elements of these countries' systems to be transferable to demonstration projects in the U.S.

Strategies and practices in off-label marketing of pharmaceuticals: a retrospective analysis of whistleblower complaints

BACKGROUND

Despite regulatory restrictions, off-label marketing of pharmaceutical products has been common in the US. However, the scope of off-label marketing remains poorly characterized. We developed a typology for the strategies and practices that constitute off-label marketing.

METHODS AND FINDINGS

We obtained unsealed whistleblower complaints against pharmaceutical companies filed in US federal fraud cases that contained allegations of off-label marketing (January 1996-October 2010) and conducted structured reviews of them. We coded and analyzed the strategic goals of each off-label marketing scheme and the practices used to achieve those goals, as reported by the whistleblowers. We identified 41 complaints arising from 18 unique cases for our analytic sample (leading to US$7.9 billion in recoveries). The off-label marketing schemes described in the complaints had three non-mutually exclusive goals: expansions to unapproved diseases (35/41, 85%), unapproved disease subtypes (22/41, 54%), and unapproved drug doses (14/41, 34%). Manufacturers were alleged to have pursued these goals using four non-mutually exclusive types of marketing practices: prescriber-related (41/41, 100%), business-related (37/41, 90%), payer-related (23/41, 56%), and consumer-related (18/41, 44%). Prescriber-related practices, the centerpiece of company strategies, included self-serving presentations of the literature (31/41, 76%), free samples (8/41, 20%), direct financial incentives to physicians (35/41, 85%), and teaching (22/41, 54%) and research activities (8/41, 20%).

CONCLUSIONS

Off-label marketing practices appear to extend to many areas of the health care system. Unfortunately, the most common alleged off-label marketing practices also appear to be the most difficult to control through external regulatory approaches.

Relationship between quality of care and negligence litigation in nursing homes

BACKGROUND

It is unclear whether high-quality health care institutions are less likely to be sued for negligence than their low-performing counterparts.

METHODS

We linked information on tort claims brought against 1465 nursing homes between 1998 and 2006 to 10 indicators of nursing home quality drawn from two U.S. national data sets: the Online Survey, Certification, and Reporting system and the Minimum Data Set Quality Measure/Indicator Report. We tested for associations between the incidence of claims and the quality measures at the facility calendar-quarter level, correcting for facility clustering and adjusting for case mix, ownership, occupancy, year, and state. Odds ratios were calculated for the effect of a change of 1 SD in each quality measure on the odds of one or more claims in each facility calendar-quarter.

RESULTS

Nursing homes with more deficiencies (odds ratio, 1.09; 95% confidence interval [CI], 1.05 to 1.13) and those with more serious deficiencies (odds ratio, 1.04; 95% CI, 1.00 to 1.08) had higher odds of being sued; this was also true for nursing homes that had more residents with weight loss (odds ratio, 1.05; 95% CI, 1.01 to 1.10) and with pressure ulcers (odds ratio, 1.09; 95% CI, 1.05 to 1.14). The odds of being sued were lower in nursing homes with more nurse's aide-hours per resident-day (odds ratio, 0.95; 95% CI, 0.91 to 0.99). However, all these effects were relatively small. For example, nursing homes with the best deficiency records (10th percentile) had a 40% annual risk of being sued, as compared with a 47% risk among nursing homes with the worst deficiency records (90th percentile).

CONCLUSIONS

The best-performing nursing homes are sued only marginally less than the worst-performing ones. Such weak discrimination may subvert the capacity of litigation to provide incentives to deliver safer care.

Are rates of pathology test ordering higher in general practices co-located with pathology collection centres?

OBJECTIVE

To determine whether rates of pathology test ordering by general practitioners in general practices co-located with pathology collection centres (PCCs) are higher than those of GPs in practices located apart from PCCs.

DESIGN, SETTING AND PARTICIPANTS

We identified all practices in the Melbourne and Sydney metropolitan areas that were co-located with PCCs (same or immediately adjacent suite) and the date co-location was established. This information was merged with the Bettering the Evaluation and Care of Health database to identify samples of GP-patient encounters in co-located practices (n = 31,700) and practices located apart from the nearest PCC (n = 289,700) over the period 2000-2009. Using Poisson regression analysis and logistic regression analysis, we compared GP test-ordering rates across the two types of practices, controlling for a range of potential confounders.

MAIN OUTCOME MEASURES

Numbers of tests ordered per encounter; likelihood of ordering one or more tests per encounter.

RESULTS

In unadjusted analyses, GPs in co-located practices ordered more pathology tests than GPs in practices located apart from PCCs (40.3 v 37.0 tests per 100 encounters, P = 0.01) and had a higher likelihood of ordering one or more tests (16.8% v 15.5% of encounters, P < 0.01). After adjusting for other predictors of test ordering, however, neither test-ordering rate (rate ratio, 0.98; 95% CI, 0.93-1.05; P = 0.56) nor likelihood of ordering one or more tests per encounter (odds ratio, 1.01; 95% CI, 0.95-1.07; P = 0.79) differed significantly by co-location status. Sub-analyses within specific test groups and types showed few systematic differences.

CONCLUSIONS

Pathology test-ordering rates are not higher in practices co-located with PCCs. To the extent inappropriate commercial influences and relationships exist in the pathology sector, GPs' test-ordering behaviour may be unaffected.

Using malpractice claims to identify risk factors for neurological impairment among infants following non-reassuring fetal heart rate patterns during labour

RATIONALE, AIMS AND OBJECTIVES

We sought to use a novel case-selection methodology to identify antenatal or intrapartum risk factors associated with neonatal neurological impairment following non-reassuring fetal heart rate patterns during labour.

METHOD

We used a retrospective case-control design with bivariate and multivariate conditional logistic regression. Cases were births in which electronic fetal monitoring (EFM) showed non-reassuring patterns and the infant had neurological disability. Controls were births in which EFM was non-reassuring but the infant was born healthy. We identified 36 cases from among malpractice claims filed with a liability insurer in Massachusetts between 1985 and 2001 and randomly selected 70 controls, matching them to cases by hospital, birth date and gestational age.

RESULTS

More cases had maternal antenatal vaginal bleeding (P = 0.004), a prolonged latent phase or protracted dilation during the first stage of labour (P = 0.03), and protracted descent or prolonged second stage (P = 0.01). More cases also had minimal variability on EFM on admission (P = 0.02) and during the second stage (P = 0.02). Multivariate analysis highlighted three significant predictors of neurological injury following complicated labour: antenatal vaginal bleeding (OR = 27.1), prolonged latent phase or protracted dilation in the first stage (OR = 4.0) and EFM showing minimal variability in the first stage (OR = 4.3).

CONCLUSION

These promising initial findings suggest that future research into outcomes from complicated labour with non-reassuring heart rate patterns should focus on maternal history of vaginal bleeding, slow labour and minimal variability on EFM.

Relationship between vehicle emissions laws and incidence of suicide by motor vehicle exhaust gas in Australia, 2001-06: an ecological analysis

BACKGROUND

Globally, suicide accounts for 5.2% of deaths among persons aged 15 to 44 years and its incidence is rising. In Australia, suicide rates peaked in 1997 and have been declining since. A substantial part of that decline stems from a plunge in suicides by one particular method: asphyxiation by motor vehicle exhaust gas (MVEG). Although MVEG remains the second most common method of suicide in Australia, its incidence decreased by nearly 70% in the decade to 2006. The extent to which this phenomenon has been driven by national laws in 1986 and 1999 that lowered permissible levels of carbon monoxide (CO) emissions is unknown. The objective of this ecological study was to test the relationship by investigating whether areas of Australia with fewer noxious vehicles per capita experienced lower rates of MVEG suicide.

METHODS AND FINDINGS

We merged data on MVEG suicides in Australia (2001-06) with data on the number and age of vehicles in the national fleet, as well as socio-demographic data from the national census. Poisson regression was used to analyse the relationship between the incidence of suicide within two levels of geographical area--postcodes and statistical subdivisions (SSDs)--and the population density of pre-1986 and pre-1999 passenger vehicles in those areas. (There was a mean population of 8,302 persons per postcode in the study dataset and 87,413 persons per SSD.) The annual incidence of MVEG suicides nationwide decreased by 57% (from 2.6 per 100,000 in 2001 to 1.1 in 2006) during the study period; the population density of pre-1986 and pre-1999 vehicles decreased by 55% (from 14.2 per 100 persons in 2001 to 6.4 in 2006) and 26% (from 44.5 per 100 persons in 2001 to 32.9 in 2006), respectively. Area-level regression analysis showed that the suicide rates were significantly and positively correlated with the presence of older vehicles. A percentage point decrease in the population density of pre-1986 vehicles was associated with a 6% decrease (rate ratio [RR] = 1.06; 95% confidence interval [CI] 1.05-1.08) in the incidence of MVEG suicide within postcode areas; a percentage point decrease in the population density of pre-1999 vehicles was associated with a 3% decrease (RR = 1.03; 95% CI 1.02-1.04) in the incidence of MVEG suicide.

CONCLUSIONS

Areas of Australia with fewer vehicles predating stringent CO emission laws experience lower rates of MVEG suicide. Although those emission laws were introduced primarily for environmental reasons, countries that lack them may miss the benefits of a serendipitous suicide prevention strategy. Please see later in the article for the Editors' Summary.

Is uptake of genetic testing for colorectal cancer influenced by knowledge of insurance implications?

OBJECTIVE

To assess whether knowledge of insurance implications influenced uptake of genetic testing by participants in a research study of the causes of colorectal cancer.

DESIGN, SETTING AND PARTICIPANTS

Analysis of uptake of genetic testing by participants in the population-based Victorian Colorectal Cancer Family Study during two periods: from 1999 to 2003, when participants were not informed of any potential effect of genetic testing conducted during the study on their eligibility for new insurance policies; and from 2003 to 2006, when the protocol was changed to provide participants with information on the potential effect of genetic testing on insurance eligibility.

MAIN OUTCOME MEASURE

Uptake of genetic testing for germline mutations in DNA mismatch repair (MMR) genes at a family cancer clinic.

RESULTS

The proportion of participants who declined genetic testing among those informed of insurance implications was more than double the proportion among those without this knowledge (29/59 [49%] v 9/47 [19%]; P = 0.002). This difference could not be explained statistically by adjusting for measured putative predictors.

CONCLUSION

Identification of people with a mutation in an MMR gene has clinical importance, and such screening may be a cost-effective way to reduce the burden of colorectal cancer in the community. If people are choosing not to obtain genetic information because of how it will affect their eligibility for insurance, reforms to existing insurance practices are indicated.

Process of care failures in breast cancer diagnosis

BACKGROUND

Process of care failures may contribute to diagnostic errors in breast cancer care.

OBJECTIVE

To identify patient- and provider-related process of care failures in breast cancer screening and follow-up in a non-claims-based cohort.

DESIGN

Retrospective chart review of a cohort of patients referred to two Boston cancer centers with new breast cancer diagnoses between January 1, 1999 and December 31, 2004.

PARTICIPANTS

We identified 2,275 women who reported > or =90 days between symptom onset and breast cancer diagnosis or presentation with at least stage II disease. We then selected the 340 (14.9%) whose physicians shared an electronic medical record. We excluded 238 subjects whose records were insufficient for review, yielding a final cohort of 102 patients.

INTERVENTIONS

None

MEASUREMENTS

We tabulated the number and types of process of care failures and examined risk factors using bivariate analyses and multivariable Poisson regression.

MAIN RESULTS

Twenty-six of 102 patients experienced > or =1 process of care failure. The most common failures occurred when physicians failed to perform an adequate physical examination, when patients failed to seek care, and when diagnostic or laboratory tests were ordered but patients failed to complete them. Failures were attributed in similar numbers to provider- and patient-related factors (n = 30 vs. n = 25, respectively). Process of care failures were more likely when the patient's primary care physician was male (IRR 2.8, 95% CI 1.2 to 6.5) and when the patient was non-white (IRR 2.8, 95% CI 1.4 to 5.7).

CONCLUSIONS

Process failures were common in this patient cohort, with both clinicians and patients contributing to breakdowns in the diagnostic process.