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HIQA EVIDENCE AND HOSPITAL SERVICE CLOSURE
 

From Dr John Barton, Consultant Cardiologist, Portiuncula Hospital, Ballinasloe.  

In an Irish Times health plus article, July 19th 2011, Dr Jacky Jones, a former regional manager of health promotion with the HSE, refers to the handling of the Roscommon A&E closure by politicians and the HSE as “a dog’s dinner” and is a metaphor of what is wrong with the Irish health service. She goes onto say that the Health Information and Quality Authority [HIQA] reports on Ennis and Mallow are crystal clear in commenting on international evidence that patients are better off being treated by doctors that treat larger numbers of patients, the volume outcome hypothesis.

I wonder how many members of the public or the medical profession have read the reference papers provided by HIQA in their reports. I do accept there is a relationship between numbers of patients treated and outcome, in particular for complex conditions such as surgery for aneurysms, certain cancers, heart disease, AIDS and those critically injured in road and other accidents. HIQA uses such information to advise government that it is appropriate to close smaller institutions because they are unsafe.

When I read the research papers in the Ennis report on volumes and outcomes, used to support HIQAs case that Ennis Hospital was unsafe and that care should be transferred to Limerick Regional hospital [regionalisation], I found that the authors of the research papers and expert commentators took a different interpretation to that of HIQA. So for instance, in both the discussion section of his New England Journal of Medicine [NEJM] study that did show that hospitals treating larger numbers of patients requiring life support breathing machines [ventilators] resulted in lower mortality, and in his subsequent letter in the Journal in response to correspondence on his paper, Professor Gordon Rubenfeld of the University of Washington states that the act of transferring such patients to regional centres may cause harm and that the regional centre may not be able to maintain high quality care if it has to deal with greater numbers of patients. We have recently seen the stress on regional centres in Limerick, in part consequent on closure of services at Ennis and Nenagh, and since the Roscommon A&E closure, even on non-regional hospitals such as Portiuncula in Ballinasloe. The overcrowding of A&E departments, best exemplified most recently by the problems in University Hospital Galway has been well shown in international research literature to be unsafe.

One of the correspondents commenting on Rubenfeld’s research, Professor Arah of the Academic Centre in Amsterdam and now at the University of California, indicates that a 10% reduction in mortality for patients requiring life support at all hospitals would result in a greater reduction in mortality than a strategy of regionalisation, a view shared by Professor Rubenfeld.

A further paper in the Ennis report deals with clots to the lung [pulmonary embolism] and is flagrantly misrepresented by HIQA to support their volume outcome argument. This is clear from a commentary on the paper by Professors Marc Carrier and Philip Wells from the Civic Hospital in Ottawa, in which they point out that the paper actually showed that hospitals treating 10 to 19 cases of lung clots per year had lower mortality than hospitals treating 20 to 41 cases per year. It was only in the very low volume hospitals with less than 10 cases per year where higher volume hospitals had a better outcome, and in that case the difference and the numbers treated at the very low volume hospitals was so small, that regionalising care for pulmonary embolism based on the differences would not be appropriate according to the authors.

It is disappointing and worrying that HIQA is not balanced in reference to this issue. As the government’s regulator on quality in health care, it should provide balanced opinion and if HIQA is unwilling to do so, then it is the responsibility of observers with alternative views to provide that balance. And so for instance, in addition to the opinions of the aforementioned researchers, a report in Health Care Quarterly, a Journal of the Institute for Clinical Evaluative Sciences in Toronto, Professor of Surgery at the University of Toronto, David Urbach, makes the point that the closure of a hospital results in disadvantaging the majority of the public requiring medical attention who attend that hospital, many with a broad range of conditions for which there is no, or minimal relationship to volumes treated, such as pneumonia, tonsillitis, urinary infection, chest pains, asthma attacks, appendicitis and so on, while a minority of the population, those with more complex disorders benefit by being transferred to the regional hospital.

Finally, how many people are aware of the potential health impact on patients of distance travelled in an ambulance or what advanced paramedics can and cannot provide in delivery of pre - hospital care? The public should be very concerned when doctors representing the HSE, including Professors, use the media to comment on health care policy outside their area of expertise, to reassure the public that all will be well for them despite closure of their local hospital emergency department. As an example, they forcefully reassure the doubting public that care by paramedics will be most acceptable and by inference as good as at your local A&E department, and that you are better off to travel the longer distance to the “most appropriate” hospital. What HIQA and medical personnel have not informed you or the government, is the findings of research in 2007 by Professor Jon Nicholl of the University of Sheffield on distance travelled in an ambulance, revealing that for every 10 kilometres covered, patients with acute respiratory, cardiac or drug overdose experience a rise in mortality of 1%. Nor have they informed you about the Ontario PreHospital Advanced Life Support Study [OPALS, NEJM 2004], one of the largest studies ever carried out regarding the value of adding advanced paramedics, individuals with greater skills and treatment capabilities than basic paramedics, to a program of rapid defibrillation with heart start machines [defibrillators] for heart attack victims, which revealed no extra benefit to such patients. The authors suggest that provision of such skilled and more costly health professionals needs to be considered in the context of efficient health spending. Other European nations such as Belgium, Holland, Germany, France and Greece up to its economic collapse, appreciate the limitations of paramedics and clearly have greater concern for patients who must travel larger distances to access hospital care and instead transport doctors and nurses out in mobile medical units to treat the most seriously ill alongside the paramedics.

It is essential to have a body such as HIQA providing guidance and regulation on quality in health care and also to have doctors involved in reform of the delivery of our health services, but the Government should more rigorously question their advice in respect of the closure of hospital services and pause to reflect on the unintended consequences of such decisions.