Impact of mental disorders on unplanned readmissions for congestive heart failure patients: a population-level study

AIMS

Reducing preventable hospitalization for congestive heart failure (CHF) patients is a challenge for health systems worldwide. CHF patients who also have a recent or ongoing mental disorder may have worse health outcomes compared with CHF patients with no mental disorders. This study examined the impact of mental disorders on 28 day unplanned readmissions of CHF patients.

METHODS AND RESULTS

This retrospective cohort study used population-level linked public and private hospitalization and death data of adults aged ≥18 years who had a CHF admission in New South Wales, Australia, between 1 January 2014 and 31 December 2020. Individuals' mental disorder diagnosis and Charlson comorbidity and hospital frailty index scores were derived from admission records. Competing risk and cause-specific risk analyses were conducted to examine the impact of having a mental disorder diagnosis on all-cause hospital readmission. Of the 65 861 adults with index CHF admission discharged alive (mean age: 78.6 ± 12.1; 48% female), 19.2% (12 675) had at least one unplanned readmission within 28 days following discharge. Adults with CHF with a mental disorder diagnosis within 12 months had a higher risk of 28 day all-cause unplanned readmission [hazard ratio (HR): 1.21, 95% confidence interval (CI): 1.15-1.27, P-value < 0.001], particularly those with anxiety disorder (HR: 1.49, 95% CI: 1.35-1.65, P-value < 0.001). CHF patients aged ≥85 years (HR: 1.19, 95% CI: 1.11-1.28), having ≥3 other comorbidities (HR: 1.35, 95% CI: 1.25-1.46), and having an intermediate (HR: 1.34, 95% CI: 1.28-1.40) or high (HR: 1.37, 95% CI: 1.27-1.47) frailty score on admission had a higher risk of unplanned readmission. CHF patients with a mental disorder who have ≥3 other comorbidities and an intermediate frailty score had the highest probability of unplanned readmission (29.84%, 95% CI: 24.68-35.73%) after considering other patient-level factors and competing events.

CONCLUSIONS

CHF patients who had a mental disorder diagnosis in the past 12 months are more likely to be readmitted compared with those without a mental disorder diagnosis. CHF patients with frailty and a mental disorder have the highest probability of readmission. Addressing mental health care services in CHF patient's discharge plan could potentially assist reduce unplanned readmissions.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability

BACKGROUND

This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change.

METHODS

We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes.

RESULTS

CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care.

CONCLUSIONS

A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

The role of frailty risk for fracture-related hospital readmission and mortality after a hip fracture

BACKGROUND

Frailty risk estimated using hospital administrative data may provide a useful clinical tool to identify older hip fracture patients at-risk of fracture-related readmissions and mortality. This study examined hip fracture hospitalisation temporal trends and explore the role of frailty risk in fracture-related readmission and mortality.

METHODS

This retrospective cohort study was conducted using linked hospital admission and mortality data in New South Wales, Australia. Patients aged ≥65 years were admitted after a hip fracture between 2014 and 2021 for temporal trends and those admitted and discharged after a hip fracture in 2014-2018 for fracture-related readmission. The Hospital Frailty Risk Score was estimated, and patients were followed for at least 36 months after discharge. A semi-competing risk analysis was used to examine the associations of frailty with fracture-related readmission and/or mortality.

RESULTS

Hip fracture hospitalisation rate was 472 per 100,000 and declined by 2.9 % (95 % confidence intervals (CI): -3.7 to -2.1) annually. Amongst 28,567 patients, 9.8 % were identified with low frailty risk, 39.4 %, intermediate frailty risk, and 50.6 % with high frailty risk. Patients with intermediate or high frailty risk had a higher chance of fracture-related readmission (Hazard ratios (HR): 1.33, 95 %CI: 1.21-1.47, HR: 1.65, 95 %CI: 1.49-1.83), death (HR: 1.50, 95 %CI: 1.38-1.63, HR: 1.80, 95 %CI: 1.65-1.96) and death post fracture-related readmission (HR: 1.32, 95 %CI: 1.12-1.56, HR: 1.56, 95 %CI: 1.32-1.84) than those with low frailty risk.

CONCLUSIONS

It appears that frailty risk estimated using hospital administrative data can contribute to identify patients who could benefit from targeted interventions to prevent further fractures.

Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms

BACKGROUND

Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation.

METHODS

Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff.

RESULTS

The program's audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy.

CONCLUSIONS

Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Incorporating a polygenic risk score-triaged coronary calcium score into cardiovascular disease examinations to identify subclinical coronary artery disease (ESCALATE): Protocol for a prospective, nonrandomized implementation trial

BACKGROUND

Identifying and targeting established modifiable risk factors has been a successful strategy for reducing the burden of coronary artery disease (CAD) at the population-level. However, up to 1-in-4 patients who present with ST elevation myocardial infarction do so in the absence of such risk factors. Polygenic risk scores (PRS) have demonstrated an ability to improve risk prediction models independent of traditional risk factors and self-reported family history, but a pathway for implementation has yet to be clearly identified. The aim of this study is to examine the utility of a CAD PRS to identify individuals with subclinical CAD via a novel clinical pathway, triaging low or intermediate absolute risk individuals for noninvasive coronary imaging, and examining the impact on shared treatment decisions and participant experience.

TRIAL DESIGN

The ESCALATE study is a 12-month, prospective, multicenter implementation study incorporating PRS into otherwise standard primary care CVD risk assessments, to identify patients at increased lifetime CAD risk for noninvasive coronary imaging. One-thousand eligible participants aged 45 to 65 years old will enter the study, which applies PRS to those considered low or moderate 5-year absolute CVD risk and triages those with CAD PRS ≥80% for a coronary calcium scan. The primary outcome will be the identification of subclinical CAD, defined as a coronary artery calcium score (CACS) >0 Agatston units (AU). Multiple secondary outcomes will be assessed, including baseline CACS ≥100 AU or ≥75th age-/sex-matched percentile, the use and intensity of lipid- and blood pressure-lowering therapeutics, cholesterol and blood pressure levels, and health-related quality of life (HRQOL).

CONCLUSION

This novel trial will generate evidence on the ability of a PRS-triaged CACS to identify subclinical CAD, as well as subsequent differences in traditional risk factor medical management, pharmacotherapy utilization, and participant experience.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12622000436774. Trial was prospectively registered on March 18, 2022. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383134.

Guiding principles for effective collaborative implementation strategies for multisite hospital improvement initiatives: a mixed-method realist evaluation of collaborative strategies used in four multisite initiatives at public hospitals in New South Wales, Australia

OBJECTIVE

Large-scale, multisite hospital improvement initiatives can advance high-quality care for patients. Implementation support is key to adoption of change in this context. Strategies that foster collaboration within local teams, across sites and between initiative developers and users are important. However not all implementation strategies are successful in all settings, sometimes realising poor or unintended outcomes. Our objective here is to develop guiding principles for effective collaborative implementation strategies for multi-site hospital initiatives.

DESIGN

Mixed-method realist evaluation. Realist studies aim to examine the underlying theories that explain differing outcomes, identifying mechanisms and contextual factors that may trigger them.

SETTING

We report on collaborative strategies used in four multi-site initiatives conducted in all public hospitals in New South Wales, Australia (n>100).

PARTICIPANTS

Using an iterative process, information was gathered on collaborative implementation strategies used, then initial programme theories hypothesised to underlie the strategies' outcomes were surfaced using a realist dialogic approach. A realist interview schedule was developed to elicit evidence for the posited initial programme theories. Fourteen participants from 20 key informants invited participated. Interviews were conducted via Zoom, transcribed and analysed. From these data, guiding principles of fostering collaboration were developed.

RESULTS

Six guiding principles were distilled: (1) structure opportunities for collaboration across sites; (2) facilitate meetings to foster learning and problem-solving across sites; (3) broker useful long-term relationships; (4) enable support agencies to assist implementers by giving legitimacy to their efforts in the eyes of senior management; (5) consider investment in collaboration as effective well beyond the current projects; (6) promote a shared vision and build momentum for change by ensuring inclusive networks where everyone has a voice.

CONCLUSION

Structuring and supporting collaboration in large-scale initiatives is a powerful implementation strategy if contexts described in the guiding principles are present.

Horizon scanning, rapid reviews and living evidence to support decision-making: lessons from the work of the Critical Intelligence Unit in New South Wales, Australia during the COVID-19 pandemic

The COVID-19 pandemic has seen an increase in rapidly disseminated scientific evidence and highlighted that traditional evidence synthesis methods, such as time and resource intensive systematic reviews, may not be successful in responding to rapidly evolving policy and practice needs. In New South Wales (NSW) Australia, the Critical Intelligence Unit (CIU) was established early in the pandemic and acted as an intermediary organisation. It brought together clinical, analytical, research, organisational and policy experts to provide timely and considered advice to decision-makers. This paper provides an overview of the functions, challenges and future implications of the CIU, particularly the Evidence Integration Team. Outputs from the Evidence Integration Team included a daily evidence digest, rapid evidence checks and living evidence tables. These products have been widely disseminated and used to inform policy decisions in NSW, making valuable impacts. Changes and innovations to evidence generation, synthesis and dissemination in response to the COVID-19 pandemic provide an opportunity to shift the way evidence is used in future. The experience and methods of the CIU have potential to be adapted and applied to the broader health system nationally and internationally.

Falls from ladders in New South Wales: A data-linkage study

INTRODUCTION

Fall from ladders is increasingly identified as a significant cause of injury and mortality, yet large-scale research into ladder fall outcomes and trends is limited.

OBJECTIVES

To explore the nature and severity of injuries resulting from ladder falls and to determine predictors of Injury Severity Score (ISS) and 6-month mortality.

METHODS

Data were obtained from the New South Wales (NSW) Trauma Registry, Admitted Patient Data Collection and Registry of Births, Deaths, and Marriages on patients aged 15 and over who had major trauma from a ladder fall and were admitted to hospital between January 1st, 2012, and July 31st, 2019. Data linkage and descriptive statistics were carried out alongside bivariate and multivariable regression analysis.

RESULTS

963 patients injured after ladder falls were identified. The mean age was 61.9 years (SD 14.2), 91.0% were male, and 489 (50.8%) were born in Australia. The height of fall was between one and five meters in 827 (86.2%) patients, and the place of fall was home and residential places in 27.5%. The most common body areas injured were the head (26.5%), spine (21.2%) and thorax (20.6%), and the median injury severity score was 17. The median length of stay of patients' in-hospital and intensive care unit was six days and two days, respectively. Six months post-discharge mortality was 6.4%. The unadjusted association between the presence of comorbidities or socio-economic class and ISS or mortality was not statistically significant. Increasing ISS was found to be associated with increasing age (Estimate (Est), 15.2; 95% Confidence Interval (CI), 12.3-18.1) and a fall height greater than five metres (Est, 5.8; CI, 3.2-8.4). Mortality was found to be associated with increasing age (Odds ratio (OR), 1.06; CI, 1.03-1.08) and increasing ISS (OR, 1.19; CI, 1.15-1.24).

CONCLUSION

People presenting to the hospital after falling from a ladder were predominately male, aged over 60 and had fallen in a residential setting. Increasing age and fall height are associated with more severe injuries.

Determinants of long-term unplanned readmission and mortality following self-inflicted and non-self-inflicted major injury: a retrospective cohort study

PURPOSE

To describe the characteristics of major injury and identify determinants of long-term unplanned readmission and mortality after self-inflicted and non-self-inflicted injury to inform potential readmission screening.

METHOD

A retrospective cohort study of 11,269 individuals aged ≥ 15 years hospitalised for a major injury during 2013-2017 in New South Wales, Australia. Unplanned readmission and mortality up to 27-month post-injury were examined. Logistic regression was used to examine predictors of unplanned readmission.

RESULTS

During the 27-month follow-up, 2700 (24.8%) individuals with non-self-inflicted and 98 (26.1%) with self-inflicted injuries had an unplanned readmission. Individuals with an anxiety-related disorder and a non-self-inflicted injury who were discharged home were three times more likely (OR: 3.27; 95%CI 2.28-4.69) or if they were discharged to a psychiatric facility were four times more likely (OR: 4.11; 95%CI 1.07-15.80) to be readmitted. Compared to individuals aged 15-24 years, individuals aged ≥ 65 years were 3 times more likely to be readmitted (OR 3.12; 95%CI 2.62-3.70). Individuals with one (OR 1.60; 95%CI 1.39-1.84) or ≥ 2 (OR 1.88; 95%CI 1.52-2.32) comorbidities, or who had a drug-related dependence (OR 1.88; 95%CI 1.52-2.31) were more likely to be readmitted. The post-discharge age-adjusted mortality rate following a self-inflicted injury (35.6%; 95%CI 29.9-41.8) was higher than for individuals with a non-self-inflicted injury (11.0%; 95%CI 10.4-11.8).

CONCLUSIONS

Unplanned readmission after injury is associated with injury intent, age, and comorbid health. Screening for anxiety and drug-related dependence after major injury, accompanied by service referrals and post-discharge follow-up, has potential to prevent readmission.

Improving access to primary health care: a cross-case comparison based on an a priori program theory

Background

Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative.

Methods

IMPACT’s evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results.

Results

Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors.

Discussion

The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways.

Conclusions

All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of ‘cases’.

Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments

INTRODUCTION

Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.

METHODS AND ANALYSIS

This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.

Does healthcare inequity reflect variations in peoples' abilities to access healthcare? Results from a multi-jurisdictional interventional study in two high-income countries

Background

Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare.

Methods

This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access.

Results

The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability.

Conclusions

We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people’s abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion.

Envisioning the future of clinical analytics: a modified Delphi process in New South Wales, Australia

Background

Clinical analytics is a rapidly developing area of informatics and knowledge mobilisation which has huge potential to improve healthcare in the future. It is widely acknowledged to be a powerful mediator of clinical decision making, patient-centred care and organisational learning. As a result, healthcare systems require a strategic foundation for clinical analytics that is sufficiently directional to support meaningful change while flexible enough to allow for iteration and responsiveness to context as change occurs.

Methods

In New South Wales, the most populous state in Australia, the Clinical Analytics Working Group was charged with developing a five-year vision for the public health system. A modified Delphi process was undertaken to elicit expert views and to reach a consensus. The process included a combination of face-to-face workshops, traditional Delphi voting via email, and innovative, real-time iteration between text re-formulation and voting until consensus was reached. The six stage process engaged 35 experts — practising clinicians, patients and consumers, managers, policymakers, data scientists and academics.

Results

The process resulted in the production of 135 ideas that were subsequently synthesised into 23 agreed statements and encapsulated in a single page (456 word) narrative.

Conclusion

The visioning process highlighted three key perspectives (clinicians, patients and managers) and the need for synchronous (during the clinical encounter) and asynchronous (outside the clinical encounter) clinical decision support and reflective practice tools; the use of new and multiple data sources and communication formats; and the role of research and education.

Assessing Performance in Health Care Using International Surveys: Are Patient and Clinician Perspectives Complementary or Substitutive

Background:

Over the last decade, international surveys of patients and clinicians have been used to compare health care across countries. Findings from these surveys have been extensively used to create aggregate scores and rankings.

Objective:

To assess the concordance of survey responses provided by patients and clinicians.

Methods:

Analysis of 16 pairs of questions that focused on coordination, organizational factors, and patient-centered competencies from the Commonwealth Fund International Health Policy Survey of older adults (2014) and of primary care physicians (2015). Concordance was assessed by comparing absolute rates and relative rankings.

Results:

In absolute terms, patients and clinicians gave differing responses for questions about coordination of care (patients were more positive) and provision of after-hours care (patients were less positive). In relative terms, country rankings were positively correlated for 5 of 16 question pairs (Spearman ρ > .6 and P < .05).

Conclusion:

Patterns of concordance between patient and clinician perspectives provides information to guide the use of survey data in performance assessment. However, this study highlights the need to assess the complementarity and substitutive nature of patients’ and clinicians’ perspectives before combining them to create aggregate assessments of performance.

Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework

RATIONALE, AIMS, AND OBJECTIVES

Unwarranted clinical variation is a topic of heightened interest in health care systems around the world. While there are many publications and reports on clinical variation, few studies are conceptually grounded in a theoretical model. This study describes the empirical foundations of the field and proposes an analytic framework.

METHOD

Structured construct mapping of published empirical studies which explicitly address unwarranted clinical variation.

RESULTS

A total of 190 studies were classified in terms of three key dimensions: perspective (assessing variation across geographical areas or across providers); criteria for assessment (measuring absolute variation against a standard, or relative variation within a comparator group); and object of analysis (using process, structure/resource, or outcome metrics).

CONCLUSION

Consideration of the results of the mapping exercise-together with a review of adjustment, explanatory and stratification variables, and the factors associated with residual variation-informed the development of an analytic framework. This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation. From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.

Combining patient, clinical and system perspectives in assessing performance in healthcare: an integrated measurement framework

BACKGROUND

The science of measuring and reporting on the performance of healthcare systems is rapidly evolving. In the past decade, across many jurisdictions, organisations tasked with monitoring progress towards reform targets have broadened their purview to take a more system-functioning approach. Their aim is to bring clarity to performance assessment, using relevant and robust concepts - and avoiding reductionist measures - to build a whole-of-system view of performance. Existing performance frameworks are not fully aligned with these developments.

METHODS

An eight stage process to develop a conceptual framework incorporated literature review, mapping, categorisation, integration, synthesis and validation of performance constructs that have been used by organisations and researchers in order to assess, reflect and report on healthcare performance.

RESULTS

A total of 19 performance frameworks were identified and included in the review. Existing frameworks mostly adopted either a logic model (inputs, outputs and outcomes), a functional, or a goal-achievement approach. The mapping process identified 110 performance terms and concepts. These were integrated, synthesised and resynthesised to produce a framework that features 12 derived constructs reflecting combinations of patients' needs and expectations; healthcare resources and structures; receipt and experience of healthcare services; healthcare processes, functions and context; and healthcare outcomes. The 12 constructs gauge performance in terms of coverage, accessibility, appropriateness, effectiveness, safety, productivity, efficiency, impact, sustainability, resilience, adaptability and equity. They reflect four performance perspectives (patient, population, delivery organisation and system).

CONCLUSIONS

Internationally, healthcare systems and researchers have used a variety of terms to categorise indicators of healthcare performance, however few frameworks are based on a theoretically-based conceptual underpinning. The proposed framework incorporates a manageable number of performance domains that together provide a comprehensive assessment, as well as conceptual and operational clarity and coherence that support multifaceted measurement systems for healthcare.

Correlating injury severity scores and major trauma volume using a state-wide in-patient administrative dataset linked to trauma registry data-A retrospective analysis from New South Wales Australia

INTRODUCTION

Trauma registries are used to analyse and report activity and benchmark quality of care at designated facilities within a trauma system. These capabilities may be enhanced with the incorporation of administrative and electronic medical record datasets, but are currently limited by the use of different injury coding systems between trauma and administrative datasets.

OBJECTIVES

Use an Abbreviated Injury Scale to International Classification of Disease (AIS-ICD) mapping tool to correlate estimated injury severity scores and major trauma volume based on administrative data collections with trauma registry data.

METHODS

Adult trauma cases were identified from the New South Wales Trauma Registry between 2012 and 2016 and linked probabilistically using age, facility and date of facility arrival to the Admitted Patient Data Collection (APDC). Estimated Injury Severity Scores (ISS) were derived using the AIS-ICD mapping tool applied to diagnoses contained in the APDC.

RESULTS

A total of eligible 13,439 cases were analysed. The overall correlation between trauma registry ISS and ISS estimated from APDC using the AIS-ICD mapping tool was low to moderate (Spearman Rho 0.41 95%CI 0.40, 0.43). Based on an estimated ISS cut-off value of 8, there was high correlation between estimated trauma volume and the number of major trauma cases at each facility (Spearman Rho 0.98, 95%CI 0.95, 0.99). Trauma Revised Injury Severity Score (TRISS) was associated with only slightly higher mortality prediction performance compared to estimated ISS (AUROC 0.76 95%CI 0.75, 0.78 versus AUROC 0.74 95%CI 0.73, 0.76).

CONCLUSION

A low to moderate correlation exists between individual patient ISS scores based on AIS to ICD mapping of in-patient data collection, but a high correlation for overall major trauma volume using the AIS-ICD mapping at facility level with comparable TRISS mortality prediction.

Barriers and facilitators to implementing playlists as a novel personalised music intervention in public healthcare settings in New South Wales, Australia

Listening to personalised music is a simple and low-cost intervention with expected therapeutic benefits, including reduced agitation, stress responses and anxiety. While there is growing evidence for the use of personalised music as a therapeutic intervention, there has been little investigation into processes and strategies that would support the implementation of playlists. The aim of this study was to identify the perceived barriers and facilitators to implementing personalised playlists on a large scale in public healthcare settings. A mixed-methods approach was used to evaluate the feasibility of the intervention in 21 different acute, sub-acute and primary healthcare settings in New South Wales (NSW), Australia, between June 2016 and June 2017. Data collection included 153 survey responses (staff n=35, patients n=49 and family members n=69), six focus groups (staff n=21) and an analysis of 37 documents. Data sources were systematically categorised using a Policy Analysis Framework. Facilitators included the use of implementation leads and volunteers, a high level of staff engagement and the integration of music selection and playlist development into routine clinical practice. Barriers included ongoing and unexpected funding, time to prepare playlists and staff turnover. The results from this study support the feasibility and acceptability of implementing playlists in different healthcare settings.

Exploring variation in low-value care: a multilevel modelling study

BACKGROUND

Whether patients receive low-value hospital care (care that is not expected to provide a net benefit) may be influenced by unmeasured factors at the hospital they attend or the hospital's Local Health District (LHD), or the patients' areas of residence. Multilevel modelling presents a method to examine the effects of these different levels simultaneously and assess their relative importance to the outcome. Knowing which of these levels has the greatest contextual effects can help target further investigation or initiatives to reduce low-value care.

METHODS

We conducted multilevel logistic regression modelling for nine low-value hospital procedures. We fit a series of six models for each procedure. The baseline model included only episode-level variables with no multilevel structure. We then added each level (hospital, LHD, Statistical Local Area [SLA] of residence) separately and used the change in the c statistic from the baseline model as a measure of the contribution of the level to the outcome. We then examined the variance partition coefficients (VPCs) and median odds ratios for a model including all three levels. Finally, we added level-specific covariates to examine if they were associated with the outcome.

RESULTS

Analysis of the c statistics showed that hospital was more important than LHD or SLA in explaining whether patients receive low-value care. The greatest increases were 0.16 for endoscopy for dyspepsia, 0.13 for colonoscopy for constipation, and 0.14 for sentinel lymph node biopsy for early melanoma. SLA gave a small increase in c compared with the baseline model, but no increase over the model with hospital. The VPCs indicated that hospital accounted for most of the variation not explained by the episode-level variables, reaching 36.8% (95% CI, 31.9-39.0) for knee arthroscopy. ERCP (8.5%; 95% CI, 3.9-14.7) and EVAR (7.8%; 95% CI, 2.9-15.8) had the lowest residual variation at the hospital level. The variables at the hospital, LHD and SLA levels that were available for this study generally showed no significant effect.

CONCLUSIONS

Investigations into the causes of low-value care and initiatives to reduce low-value care might best be targeted at the hospital level, as the high variation at this level suggests the greatest potential to reduce low-value care.

Moving regional health services planning and management to a population-based approach: implementation of the Regional Operating Model (ROM) in Victoria, Australia

Various jurisdictions are moving towards population-based approaches to plan and manage healthcare services. The evidence on the implementation of these models remains limited. The aim of this study is to evaluate the effect of a regional operating model (ROM) on internal functioning and stakeholder engagement of a regional office. Semi-structured interviews and focus groups with staff members and stakeholders of the North West Metropolitan Regional office in Victoria, Australia, were conducted. Overall, the ROM was perceived as relevant to staff and stakeholders. However, creating shared objectives and priorities across a range of organisations remained a challenge. Area-based planning and management is seen as simplifying management of contracts; however, reservations were expressed about moving from specialist to more generalist approaches. A clearer articulation of the knowledge, skills and competencies required by staff would further support the implementation of the model. The ROM provides a platform for public services and stakeholders to discuss, negotiate and deliver on shared outcomes at the regional level. It provides an integrated managerial platform to improve service delivery and avoid narrow programmatic approaches.

The influence of patient-clinician ethnocultural and language concordance on continuity and quality of care: a cross-sectional analysis

BACKGROUND

Concordance refers to shared characteristics between a clinician and patient, such as ethnicity or language. The purpose of this study was to examine whether patient-clinician concordance is associated with patient-reported continuity of care (relational, informational and management) and patient-reported impacts of care (quality and empowerment).

METHODS

This is a secondary analysis of cross-sectional patient surveys that were administered across British Columbia, Manitoba and Quebec using random digit dialling. Participants were adults who spoke English, French, Mandarin, Cantonese or Punjabi and who had visited a primary care clinician in the previous 12 months (n = 3156). Patients self-identified as being of European, Chinese, South Asian and Indigenous descent. Outcome measures included patients' perceptions of continuity, quality and empowerment. Adjusted logistic regression models and odds ratio were generated.

RESULTS

More than 64% of non-Indigenous respondents reported ethnocultural concordance. Ethnocultural concordance was associated with higher odds of relational and management continuity. This same pattern held when there was both ethnocultural and language concordance. No association was found between language concordance and any outcome measure. Chinese participants reported lower quality (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.12-0.48), as did South Asian participants (OR 0.17, 95% CI 0.09-0.31) than did participants of European descent.

INTERPRETATION

Higher relational and management continuity is more likely with the presence of patient-clinician ethnocultural and language concordance. Lower continuity and quality reported by Chinese and South Asian particpants could indicate important health care disparities.

The Influence of Individuals' Vulnerabilities and Their Interactions on the Assessment of a Primary Care Experience

This study examines the relationship between the vulnerabilities of individuals and their assessments of their primary care experiences in the setting of a universal care system. It focuses on 2 specific objectives: (1) evaluating the influence of each of the 5 vulnerabilities on the assessment of the care experience; (2) evaluating the influence of the interactions between the different types of vulnerabilities on the assessment of the care experience. The study identifies the primary care experience of 9,206 people. The health-related, biological, material, relational, and cultural vulnerabilities are also evaluated. Generally, individuals' vulnerabilities are associated with a positive assessment of the primary care experience except for the cultural vulnerability. Material vulnerability is most frequently associated with a positive assessment of the primary care experience. The interactions between the multiple vulnerabilities present for one individual often modify the effect of vulnerability on the assessment of the experience of care. The positive effect of a vulnerability on the assessment of the care experience often increases in the presence of a second vulnerability, especially the health-related vulnerability. The simultaneous presence of health-related vulnerability cancels the negative influence of cultural vulnerability on the assessment of the primary care experience.

Dimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions

BACKGROUND

Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated.

OBJECTIVE

The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams.

METHODS

Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with face-to-face group retreats, using a Collaborative Reflexive Deliberative Approach.

RESULTS

Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts.

CONCLUSION

The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries

BACKGROUND

Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm.

OBJECTIVE

To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices.

METHODS

An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies.

RESULTS

Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect.

CONCLUSION

The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach

BACKGROUND

Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies.

OBJECTIVE

To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials.

METHODS

We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights.

RESULTS

CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions.

CONCLUSIONS

The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

Is the weekend effect really ubiquitous? A retrospective clinical cohort analysis of 30-day mortality by day of week and time of day using linked population data from New South Wales, Australia

OBJECTIVE

To examine the associations between day of week and time of admission and 30-day mortality for six clinical conditions: ischaemic and haemorrhagic stroke, acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease and congestive heart failure.

DESIGN

Retrospective population-based cohort analyses. Hospitalisation records were linked to emergency department and deaths data. Random-effect logistic regression models were used, adjusting for casemix and taking into account clustering within hospitals.

SETTING

All hospitals in New South Wales, Australia, from July 2009 to June 2012.

PARTICIPANTS

Patients admitted to hospital with a primary diagnosis for one of the six clinical conditions examined.

OUTCOME MEASURES

Adjusted ORs for all-cause mortality within 30 days of admission, by day of week and time of day.

RESULTS

A total of 148 722 patients were included in the study, with 17 721 deaths within 30 days of admission. Day of week of admission was not associated with significantly higher likelihood of death for five of the six conditions after adjusting for casemix. There was significant variation in mortality for chronic obstructive pulmonary disease by day of week; however, this was not consistent with a strict weekend effect (Thursday: OR 1.29, 95% CI 1.12 to 1.48; Friday: OR 1.25, 95% CI 1.08 to 1.44; Saturday: OR 1.18, 95% CI 1.02 to 1.37; Sunday OR 1.05, 95% CI 0.90 to 1.22; compared with Monday). There was evidence for a night effect for patients admitted for stroke (ischaemic: OR 1.30, 95% CI 1.17 to 1.45; haemorrhagic: OR 1.58, 95% CI 1.40 to 1.78).

CONCLUSIONS

Mortality outcomes for these conditions, adjusted for casemix, do not vary in accordance with the weekend effect hypothesis. Our findings support a growing body of evidence that questions the ubiquity of the weekend effect.

Factors associated with multiple barriers to access to primary care: an international analysis

Background

Disparities in access to primary care (PC) have been demonstrated within and between health systems. However, few studies have assessed the factors associated with multiple barriers to access occurring along the care-seeking process in different healthcare systems.

Methods

In this secondary analysis of the 2016 Commonwealth Fund International Health Policy Survey of Adults, access was represented through participant responses to questions relating to access barriers either before or after reaching the PC practice in 11 countries (Australia, Canada, France, Germany, Norway, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and United States). The number of respondents in each country ranged from 1000 to 7000 and the response rates ranged from 11% to 47%. We used multivariable logistic regression models within each of eleven countries to identify disparities in response to the access barriers by age, sex, immigrant status, income and the presence of chronic conditions.

Results

Overall, one in five adults (21%) experienced multiple barriers before reaching PC practices. After reaching care, an average of 16% of adults had two or more barriers. There was a sixfold difference between nations in the experience of these barriers to access. Vulnerable groups experiencing multiple barriers were relatively consistent across countries. People with lower income were more likely to experience multiple barriers, particularly before reaching primary care practices. Respondents with mental health problems and those born outside the country displayed substantial vulnerability in terms of barriers after reaching care.

Conclusion

A greater understanding of the multiple barriers to access to PC across the stages of the care-seeking process may help to inform planning and performance monitoring of disparities in access. Variation across countries may reveal organisational and system drivers of access, and inform efforts to improve access to PC for vulnerable groups. The cumulative nature of these barriers remains to be assessed.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0740-1) contains supplementary material, which is available to authorized users.

Accuracy of inter-hospital transfer information in Australian hospital administrative databases

Inter-hospital transfers improve care delivery for which sending and receiving hospitals both accountable for patient outcomes. We aim to measure accuracy in recorded patient transfer information (indication of transfer and hospital identifier) over 2 years across 121 acute hospitals in New South Wales, Australia. Accuracy rate for 127,406 transfer-out separations was 87 per cent, with a low variability across hospitals (10% differences); it was 65 per cent for 151,978 transfer-in admissions with a greater inter-hospital variation (36% differences). Accuracy rate varied by departure and arrival pathways; at receiving hospitals, it was lower for transfer-in admission via emergency department (incidence rate ratio = 0.52, 95% confidence interval: 0.51-0.53) versus direct admission. Transfer-out data were more accurate for transfers to smaller hospitals (incidence rate ratio = 1.06, 95% confidence interval: 1.03-1.08) or re-transfers (incidence rate ratio > 1.08). Incorporation of transfer data from sending and receiving hospitals at patient level in administrative datasets and standardisation of documentation across hospitals would enhance accuracy and support improved attribution of hospital performance measures.

Barriers to accessing primary health care: comparing Australian experiences internationally

Most highly developed economies have embarked on a process of primary health care (PHC) transformation. To provide evidence on how nations vary in terms of accessing PHC, the aim of this study is to describe the extent to which barriers to access were experienced by adults in Australia compared with other countries. Communities participating in an international research project on PHC access interventions were engaged to prioritise questions from the 2013 Commonwealth Fund International Health Policy Survey within a framework that conceptualises access across dimensions of approachability, acceptability, availability, affordability and appropriateness. Logistic regression models, with barriers to access as outcomes, found measures of availability to be a problematic dimension in Australia; 27% of adults experienced difficulties with out-of-hours access, which was higher than 5 of 10 comparator countries. Although less prevalent, affordability was also perceived as a substantial barrier; 16% of Australians said they had forgone health care due to cost in the previous year. After adjusting for age and health status, this barrier was more common in Australia than 7 of 10 countries. Findings of this integrated assessment of barriers to access offer insights for policymakers and researchers on Australia's international performance in this crucial PHC domain.

What role does performance information play in securing improvement in healthcare? a conceptual framework for levers of change

OBJECTIVE

Across healthcare systems, there is consensus on the need for independent and impartial assessment of performance. There is less agreement about how measurement and reporting performance improves healthcare. This paper draws on academic theories to develop a conceptual framework-one that classifies in an integrated manner the ways in which change can be leveraged by healthcare performance information.

METHODS

A synthesis of published frameworks.

RESULTS

The framework identifies eight levers for change enabled by performance information, spanning internal and external drivers, and emergent and planned processes: (1) cognitive levers provide awareness and understanding; (2) mimetic levers inform about the performance of others to encourage emulation; (3) supportive levers provide facilitation, implementation tools or models of care to actively support change; (4) formative levers develop capabilities and skills through teaching, mentoring and feedback; (5) normative levers set performance against guidelines, standards, certification and accreditation processes; (6) coercive levers use policies, regulations incentives and disincentives to force change; (7) structural levers modify the physical environment or professional cultures and routines; (8) competitive levers attract patients or funders.

CONCLUSION

This framework highlights how performance measurement and reporting can contribute to eight different levers for change. It provides guidance into how to align performance measurement and reporting into quality improvement programme.

Out-of-pocket healthcare expenditure and chronic disease - do Australians forgo care because of the cost?

Although we do know that out-of-pocket healthcare expenditure is relatively high in Australia, little is known about what health conditions are associated with the highest out-of-pocket expenditure, and whether the cost of healthcare acts as a barrier to care for people with different chronic conditions. Cross-sectional analysis using linear and logistic regression models applied to the Commonwealth Fund international health policy survey of adults aged 18 years and over was conducted in 2013. Adults with asthma, emphysema and chronic obstructive pulmonary disease (COPD) had 109% higher household out-of-pocket healthcare expenditure than did those with no health condition (95% CI: 50-193%); and adults with depression, anxiety and other mental health conditions had 95% higher household out-of-pocket expenditure (95% CI: 33-187%). People with a chronic condition were also more likely to forego care because of cost. People with depression, anxiety and other mental health conditions had 7.65 times higher odds of skipping healthcare (95% CI: 4.13-14.20), and people with asthma, emphysema and chronic obstructive pulmonary disease had 6.16 times higher odds of skipping healthcare (95% CI: 3.30-11.50) than did people with no health condition. People with chronic health conditions in Canada, the United Kingdom, Germany, France, Norway, Sweden and Switzerland were all significantly less likely to skip healthcare because of cost than were people with a condition in Australia. The out-of-pocket cost of healthcare in Australia acts as a barrier to accessing treatment for people with chronic health conditions, with people with mental health conditions being likely to skip care. Attention should be given to the accessibility and affordability of mental health services in Australia.

Exploring interhospital transfers and partnerships in the hospital sector in New South Wales, Australia

Objective The aim of the present study was to explore characteristics of interhospital transfers (IHT) and sharing of care among hospitals in New South Wales (NSW), Australia. Methods Data were extracted from patient-level linked hospital administrative datasets for separations from all NSW acute care hospitals from 1 July 2013 to 30 June 2015. Patient discharge and arrival information was used to identify IHTs. Characteristics of patients and related hospitals were then analysed. Results Transfer-in patients accounted for 3.9% of all NSW admitted patients and, overall, 7.3% of NSW admissions were associated with transfers (IHT rate). Patients with injuries and circulatory system diseases had the highest IHT rate, accounting for one-third of all IHTs. Patients were more often transferred to larger than smaller hospitals (61% vs 29%). Compared with private hospitals, public hospitals had a higher IHT rate (8.4% vs 5.1%) and a greater proportion of transfer-out IHTs (52% vs 28%). Larger public hospitals had lower IHT rates (3–8%) compared with smaller public hospitals (13–26%). Larger public hospitals received and retransferred higher proportions of IHT patients (52–58% and 11% respectively) than their smaller counterparts (26–30% and 2–3% respectively). Less than one-quarter of IHTs were between the public and private sectors or between government health regions. The number of interacting hospitals and their interactions varied across hospital peer groups. Conclusion NSW IHTs were often to hospitals with greater speciality services. The patterns of interhospital interactions could be affected by organisational and regional preferences. What is known about the topic? IHTs aim to provide efficient and effective care. Nonetheless, information on transfers and the sharing of care among hospitals in an Australian setting is lacking. Studies of transfers and hospital partnership patterns will inform efforts to improve patient-centred transfers and hospital accountability in terms of end outcomes for patients. What does this paper add? Transfer-in patients accounted for 3.9% of all NSW admissions; they were often (61%) transferred to hospitals with greater speciality services. The number of IHTs and sharing of care among hospitals varied across hospital peer groups, and could have been affected by organisational and regional preferences. What are the implications for practitioners? The findings of the present study suggest that different patterns of IHTs may not only have resulted from clinical priorities, but that organisational and regional preferences are also likely to be influential factors. Patient-centred IHTs and the development of guidelines need to be pursued to enhance the care and functionality of healthcare. Patient sharing should be acknowledged in hospital and regional performance profiling.

Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping review

Access to community-based primary health care (hereafter, 'primary care') is a priority in many countries. Health care systems have emphasized policies that help the community 'get the right service in the right place at the right time'. However, little is known about organizational interventions in primary care that are aimed to improve access for populations in situations of vulnerability (e.g., socioeconomically disadvantaged) and how successful they are. The purpose of this scoping review was to map the existing evidence on organizational interventions that improve access to primary care services for vulnerable populations. Scoping review followed an iterative process. Eligibility criteria: organizational interventions in Organisation for Economic Cooperation and Development (OECD) countries; aiming to improve access to primary care for vulnerable populations; all study designs; published from 2000 in English or French; reporting at least one outcome (avoidable hospitalization, emergency department admission, or unmet health care needs).

SOURCES

Main bibliographic databases (Medline, Embase, CINAHL) and team members' personal files.

STUDY SELECTION

One researcher selected relevant abstracts and full text papers. Theory-driven synthesis: The researcher classified included studies using (i) the 'Patient Centered Access to Healthcare' conceptual framework (dimensions and outcomes of access to primary care), and (ii) the classification of interventions of the Cochrane Effective Practice and Organization of Care. Using pattern analysis, interventions were mapped in accordance with the presence/absence of 'dimension-outcome' patterns. Out of 8,694 records (title/abstract), 39 studies with varying designs were included. The analysis revealed the following pattern. Results of 10 studies on interventions classified as 'Formal integration of services' suggested that these interventions were associated with three dimensions of access (approachability, availability and affordability) and reduction of hospitalizations (four/four studies), emergency department admissions (six/six studies), and unmet healthcare needs (five/six studies). These 10 studies included seven non-randomized studies, one randomized controlled trial, one quantitative descriptive study, and one mixed methods study. Our results suggest the limited breadth of research in this area, and that it will be feasible to conduct a full systematic review of studies on the effectiveness of the formal integration of services to improve access to primary care services for vulnerable populations.

Scoping of models to support population-based regional health planning and management: comparison with the regional operating model in Victoria, Australia

Objective The aim of the present study was to try to understand the breadth and comprehensiveness of a regional operating model (ROM) developed within the Victorian Department of Health's North West Metropolitan Region office in Melbourne, Australia. Methods A published literature search was conducted, with additional website scanning, snowballing technique and expert consultation, to identify existing operating models. An analytical grid was developed covering 16 components to evaluate the models and assess the exhaustiveness of the ROM. Results From the 34 documents scoped, 10 models were identified to act as a direct comparator to the ROM. These concerned models from Australia (n=5) and other comparable countries (Canada, UK). The ROM was among the most exhaustive models, covering 13 of 16 components. It was one of the few models that included intersectoral actions and levers of influence. However, some models identified more precisely the planning tools, prioritisation criteria and steps, and the allocation mechanisms. Conclusions The review finds that the ROM appears to provide a wide coverage of aspects of planning and integrates into a single model some of the distinctive elements of the other models scoped. What is known about the topic? Various jurisdictions are moving towards a population-based approach to manage public services with regard to the provision of individual medical and social care. Various models have been proposed to guide the planning of services from a population health perspective. What does this paper add? This paper assesses the coverage of attributes of operating models supporting a population health planning approach to the management of services at the regional or local level. It provides a scoping of current models proposed to organise activities to ensure an integrated approach to the provision of services and compares the scoped models to a model recently implemented in Victoria, Australia. What are the implications for practitioners? This paper highlights the relative paucity of operating models describing in concrete terms how to manage medical and social services from a population perspective and encourages organisations that are accountable for securing population health to clearly articulate their own operating model. It outlines strengths and potential gaps in current models.

Equity of access to primary healthcare for vulnerable populations: the IMPACT international online survey of innovations

BACKGROUND

Improving access to primary healthcare (PHC) for vulnerable populations is important for achieving health equity, yet this remains challenging. Evidence of effective interventions is rather limited and fragmented. We need to identify innovative ways to improve access to PHC for vulnerable populations, and to clarify which elements of health systems, organisations or services (supply-side dimensions of access) and abilities of patients or populations (demand-side dimensions of access) need to be strengthened to achieve transformative change. The work reported here was conducted as part of IMPACT (Innovative Models Promoting Access-to-Care Transformation), a 5-year Canadian-Australian research program aiming to identify, implement and trial best practice interventions to improve access to PHC for vulnerable populations. We undertook an environmental scan as a broad screening approach to identify the breadth of current innovations from the field.

METHODS

We distributed a brief online survey to an international audience of PHC researchers, practitioners, policy makers and stakeholders using a combined email and social media approach. Respondents were invited to describe a program, service, approach or model of care that they considered innovative in helping vulnerable populations to get access to PHC. We used descriptive statistics to characterise the innovations and conducted a qualitative framework analysis to further examine the text describing each innovation.

RESULTS

Seven hundred forty-four responses were recorded over a 6-week period. 240 unique examples of innovations originating from 14 countries were described, the majority from Canada and Australia. Most interventions targeted a diversity of population groups, were government funded and delivered in a community health, General Practice or outreach clinic setting. Interventions were mainly focused on the health sector and directed at organisational and/or system level determinants of access (supply-side). Few innovations were developed to enhance patients' or populations' abilities to access services (demand-side), and rarely did initiatives target both supply- and demand-side determinants of access.

CONCLUSIONS

A wide range of innovations improving access to PHC were identified. The access framework was useful in uncovering the disparity between supply- and demand-side dimensions and pinpointing areas which could benefit from further attention to close the equity gap for vulnerable populations in accessing PHC services that correspond to their needs.

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries

Context

A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood.

Objective

To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices.

Design

Collaborative synthesis of 12 mixed methods studies.

Setting

Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec).

Methods

We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context.

Results

There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups.

Conclusion

The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level.

The primary-specialty care interface in chronic diseases: patient and practice characteristics associated with co-management

OBJECTIVE

Specialist physicians may act either as consultants or co-managers for patients with chronic diseases along with their primary healthcare (PHC) physician. We assessed factors associated with specialist involvement.

METHODS

We used questionnaire and administrative data to measure co-management and patient and PHC practice characteristics in 702 primary care patients with common chronic diseases. Analysis included multilevel logistic regressions.

RESULTS

In all, 27% of the participants were co-managed. Persons with more severe chronic diseases and lower health-related quality of life were more likely to be co-managed. Persons who were older, had a lower socioeconomic status, resided in rural regions and who were followed in a PHC practice with an advanced practice nurse were less likely to be co-managed.

DISCUSSION

Co-management of patients with chronic diseases by a specialist is associated with higher clinical needs but demonstrates social inequalities. PHC practices more adapted to chronic care may help optimize specialist resources utilization.

Patient-reported confidence in primary healthcare: are there disparities by ethnicity or language?

OBJECTIVE

To examine whether confidence in primary healthcare (PHC) differs among ethnic-linguistic groups and which PHC experiences are associated with confidence.

DESIGN

A cross-sectional study where patient surveys were administered using random digit dialling. Regression models identify whether ethnic-linguistic group remains significantly associated with confidence in PHC.

SETTING

British Columbia, Canada.

MAIN OUTCOME MEASURES

Confidence in PHC measured using a 0-10 scale, where a higher score indicates increased confidence in the ability to get needed PHC services.

PARTICIPANTS

Community-dwelling adults in the following ethnic-linguistic groups: English-speaking Chinese, Chinese-speaking Chinese, English-speaking South Asians, Punjabi-speaking South Asians and English-speakers of presumed European descent.

FINDINGS

Based on a sample of 1211 respondents, confidence in PHC differed by ethnicity and the ability to speak English. Most of the differences in confidence by ethnic-linguistic group can be explained by various aspects of care experience. Patient experiences associated with lower confidence in PHC were: if care was received outside Canada, having to wait months to see their regular doctor and rating the quality of healthcare as good or fair/poor. Better patient experiences of their doctor being concerned about their feelings and being respectful and if they found wait times acceptable were associated with higher levels of confidence in PHC. The final regression model explained 30% of the variance.

CONCLUSIONS

Improving the delivery of PHC services through positive interactions between patients and their usual provider and acceptability of wait times are examples of how the PHC system can be strengthened.

Patient-centred access to health care: conceptualising access at the interface of health systems and populations

Background

Access is central to the performance of health care systems around the world. However, access to health care remains a complex notion as exemplified in the variety of interpretations of the concept across authors. The aim of this paper is to suggest a conceptualisation of access to health care describing broad dimensions and determinants that integrate demand and supply-side-factors and enabling the operationalisation of access to health care all along the process of obtaining care and benefiting from the services.

Methods

A synthesis of the published literature on the conceptualisation of access has been performed. The most cited frameworks served as a basis to develop a revised conceptual framework.

Results

Here, we view access as the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services, and to actually have a need for services fulfilled. We conceptualise five dimensions of accessibility: 1) Approachability; 2) Acceptability; 3) Availability and accommodation; 4) Affordability; 5) Appropriateness. In this framework, five corresponding abilities of populations interact with the dimensions of accessibility to generate access. Five corollary dimensions of abilities include: 1) Ability to perceive; 2) Ability to seek; 3) Ability to reach; 4) Ability to pay; and 5) Ability to engage.

Conclusions

This paper explains the comprehensiveness and dynamic nature of this conceptualisation of access to care and identifies relevant determinants that can have an impact on access from a multilevel perspective where factors related to health systems, institutions, organisations and providers are considered with factors at the individual, household, community, and population levels.

The influence of primary health care organizational models on patients’ experience of care in different chronic disease situations

Objectives

To examine the extent to which experience of care varies across chronic diseases, and to analyze the relationship of primary health care (PHC) organizational models with the experience of care reported by patients in different chronic disease situations.

Methods

We linked a population survey and a PHC organizational survey conducted in two regions of Quebec. We identified five groups of chronic diseases and contrasted these with a no–chronic-disease group.

Results

Accessibility of care is low for all chronic conditions and shows little variation across diseases. The contact and the coordination-integrated models are the most accessible, whereas the single-provider model is the least. Process and outcome indices of care experience are much higher than accessibility for all conditions and vary across diseases, with the highest being for cardiovascular-risk-factors and the lowest for respiratory diseases (for people aged 44 and under). However, as we move from risk factors to more severe chronic conditions, the coordination-integrated and community models are more likely to generate better process of care, highlighting the greater potential of these two models to meet the needs of more severely chronically ill individuals within the Canadian health care system.

Primary health care in Canada: systems in motion

CONTEXT

During the 1980s and 1990s, innovations in the organization, funding, and delivery of primary health care in Canada were at the periphery of the system rather than at its core. In the early 2000s, a new policy environment emerged.

METHODS

This policy analysis examines primary health care reform efforts in Canada during the last decade, drawing on descriptive information from published and gray literature and from a series of semistructured interviews with informed observers of primary health care in Canada.

FINDINGS

Primary health care in Canada has entered a period of potentially transformative change. Key initiatives include support for interprofessional primary health care teams, group practices and networks, patient enrollment with a primary care provider, financial incentives and blended-payment schemes, development of primary health care governance mechanisms, expansion of the primary health care provider pool, implementation of electronic medical records, and quality improvement training and support.

CONCLUSIONS

Canada's experience suggests that primary health care transformation can be achieved voluntarily in a pluralistic system of private health care delivery, given strong government and professional leadership working in concert.

The influence of primary health care organizational models on patients' experience of care in different chronic disease situations

OBJECTIVES

To examine the extent to which experience of care varies across chronic diseases, and to analyze the relationship of primary health care (PHC) organizational models with the experience of care reported by patients in different chronic disease situations.

METHODS

We linked a population survey and a PHC organizational survey conducted in two regions of Quebec. We identified five groups of chronic diseases and contrasted these with a no-chronic-disease group.

RESULTS

Accessibility of care is low for all chronic conditions and shows little variation across diseases. The contact and the coordination-integrated models are the most accessible, whereas the single-provider model is the least. Process and outcome indices of care experience are much higher than accessibility for all conditions and vary across diseases, with the highest being for cardiovascular-risk-factors and the lowest for respiratory diseases (for people aged 44 and under). However, as we move from risk factors to more severe chronic conditions, the coordination-integrated and community models are more likely to generate better process of care, highlighting the greater potential of these two models to meet the needs of more severely chronically ill individuals within the Canadian health care system.

Acceptance of screening and completion of treatment for latent tuberculosis infection among refugee claimants in Canada

SETTING

Primary care clinic for refugee claimants, Montreal, Canada.

OBJECTIVES

To identify factors linked to the acceptance of the tuberculin skin test (TST), and assess completion of treatment for latent tuberculosis infection (LTBI).

DESIGN

Asylum seekers consulting for a medical complaint or medical immigration examination between February and October 1999 were assessed for eligibility. Personal and clinical information was gathered prospectively by questionnaire. Hospital files were reviewed to assess completion of LTBI treatment.

RESULTS

In our study, 296 subjects (72.4% of 409 eligible) were offered TST, of whom 227 accepted (76.7%). Of these, 49 (24.9%) had a TST > or = 10 mm and 24 (49%) completed 6 months of LTBI treatment. Logistic regression models showed that patients who had never had a TST (OR 3.2, 95%CI 1.34-7.6) or had no temporary exclusion criteria (OR 4.0, 95%CI 1.6-9.9) were more likely to accept TST. Perceiving tuberculosis as a severe disease (OR 0.29, 95%CI 0.09-0.91) and consulting for an immigration examination (OR 0.42, 95%CI 0.18-0.98) was associated with refusal of TST. Increasing age was found to be independently associated with a positive TST (OR 1.06, 95%CI 1.01-1.12). Variability in the proportion of positive results was found between TST readers.

CONCLUSION

This study supports the feasibility of screening refugee claimants for LTBI during medical consultation and of developing organizational links to ensure completion of LTBI treatment.