Measuring performance in allied health professional role substitution models of care: a clinician survey

BACKGROUND

Professional role substitution models of care have emerged as a key strategy to address increasing healthcare demand. Gaining insights from those actively engaged in the process of these models' implementation and evaluation is pivotal to ensuring sustainability and further successful implementation. The purpose of this study was to describe allied-health clinicians' perceptions, practice, and experiences of healthcare performance evaluation in professional role substitution models of care.

METHODS

Data were collected via an online platform between 22 June - 22 July 2022 using a combination of convenience and network-based sampling of allied-health clinicians involved or interested in the implementation and evaluation of professional role substitution models of care. Clinicians answered 25 questions which consisted of demographic and targeted questions regarding performance evaluation across six domains of healthcare quality (effectiveness, safety, appropriateness, access & equity, continuity of care, and cost, efficiency, productivity & sustainability).

RESULTS

A total of 102 clinicians accessed the survey, with 72 providing complete survey data. Eleven allied-health professions were represented, working across twelve specialities in thirteen hospital and health services. Whilst most allied-health clinicians (93-100%) supported measuring performance in each of the six healthcare quality domains, only 26-58% were measuring these domains in practice. Allied-health leadership support (62.5%), clinician drive (62.5%), consumer engagement (50%) and medical support (46%) were enablers whilst a lack of resources (human, time, financial (47%)), healthcare performance frameworks and/or policies (40%) were identified as barriers. Given the opportunity, clinicians would invest the most financial resources in digital solutions as a core strategy to improve performance evaluation.

CONCLUSIONS

Allied-health professionals expressed strong support for principles of performance evaluation, however in practice, performance evaluation is still in its infancy in professional role substitution models of care. Organisations can implement strategies that maximise the enablers whilst addressing barriers identified to improve performance evaluation in these models of care.

Health-related quality of life in people with different diabetes-related foot ulcer health states: A cross-sectional study of healed, non-infected, infected, hospitalised and amputated ulcer states

AIMS

Diabetes-related foot ulcers (DFU) are a leading cause of infection, hospitalisation and amputation. However, to our knowledge no studies have compared the health-related quality of life (HRQoL) of people with DFU that were infected, hospitalised or amputated. This study aimed to investigate and compare the HRQoL of different groups of people with healed, non-infected, infected, hospitalised, or amputated DFU.

METHODS

This was a multi-centre cross-sectional study measuring the HRQoL of patients, attending one of 18 Diabetic Foot Services across Queensland, Australia, with one of five DFU health states: healed, non-infected, infected, hospitalised, amputated. HRQoL was measured using the EQ-5D-5L to estimate age-sex adjusted utility values.

RESULTS

Of 376 included patients (mean age 63 (12) years, 75% male), age-sex adjusted HRQoL utility estimates (95% CIs) were: healed DFU 0.57 (0.51-0.64), non-infected DFU 0.55 (0.49-0.62), infected DFU 0.45 (0.36-0.55), hospitalised DFU 0.53 (0.42-0.64), and amputated DFU 0.55 (0.46-0.63).

CONCLUSION

People in any DFU health state have considerably reduced HRQoL, with greatest reductions in those with infected DFU. These findings provide valuable HRQoL estimates and comparisons for several different important DFU health states, adding to our understanding of the impact of DFU on HRQoL and facilitating future economic evaluations.

Evaluation of a teleaudiology service in regional Australia

OBJECTIVE

Evaluate accessibility, effectiveness, acceptability and efficiency of a student- assisted teleaudiology model of care in a regional hospital in Queensland, Australia.

DESIGN

Prospective mixed method service evaluation study.

STUDY SAMPLE

Demographic, service and satisfaction data were collected from 233 patients (children aged ≥5 and adults) who received teleaudiology assessment. Satisfaction data was collected from 27 hospital clinic staff (medical, nursing and clinic assistants) and 28 university audiology clinical educator participants. Experience and satisfaction data were collected from 16 teleaudiology clinic university students. Quantitative data was analysed using SPSS software. Qualitative data were analysed using inductive content analysis.

RESULTS

Following introduction of the teleaudiology service in 2017 and evaluation during the first 6 months, 95% of patients were able to access audiology assessments on the same day as their Ear, Nose and Throat appointments. New referrals to the service were seen within a month. The audiology assessment battery was completed 95% of the time within an average of 33 minutes by the end of the study period. Patients, hospital and university staff and students reported high satisfaction with their experiences of teleaudiology, including its convenience and efficiency.

CONCLUSIONS

A student-assisted teleaudiology model of care can deliver accessible, effective, and efficient services with high levels of satisfaction by participants.

Developing a knowledge translation program for health practitioners: Allied Health Translating Research into Practice

Background

Front-line health practitioners lack confidence in knowledge translation, yet they are often required to undertake projects to bridge the knowledge-practice gap. There are few initiatives focused on building the capacity of the health practitioner workforce to undertake knowledge translation, with most programs focusing on developing the skills of researchers. This paper reports the development and evaluation of a knowledge translation capacity building program for allied health practitioners located over geographically dispersed locations in Queensland, Australia.

Methods

Allied Health Translating Research into Practice (AH-TRIP) was developed over five years with consideration of theory, research evidence and local needs assessment. AH-TRIP includes five components: training and education; support and networks (including champions and mentoring); showcase and recognition; TRIP projects and implementation; evaluation. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation Maintenance) guided the evaluation plan, with this paper reporting on the reach (number, discipline, geographical location), adoption by health services, and participant satisfaction between 2019 and 2021.

Results

A total of 986 allied health practitioners participated in at least one component of AH-TRIP, with a quarter of participants located in regional areas of Queensland. Online training materials received an average of 944 unique page views each month. A total of 148 allied health practitioners have received mentoring to undertake their project, including a range of allied health disciplines and clinical areas. Very high satisfaction was reported by those receiving mentoring and attending the annual showcase event. Nine of sixteen public hospital and health service districts have adopted AH-TRIP.

Conclusion

AH-TRIP is a low-cost knowledge translation capacity building initiative which can be delivered at scale to support allied health practitioners across geographically dispersed locations. Higher adoption in metropolitan areas suggests that further investment and targeted strategies are needed to reach health practitioners working in regional areas. Future evaluation should focus on exploring the impact on individual participants and the health service.

Allied health pre-entry student clinical placement capacity: can it be sustained?

Objective Meeting the demand for clinical placements in an environment of increasing university cohort growth and changes in health service delivery models is challenging. This paper describes the outcomes of a quality review activity designed to gain key stakeholder perspectives on the enablers and barriers to sustaining effort to placement provision and reports on: (1) measures used to determine the effect of a jurisdiction-wide initiative in clinical education for five allied health professions; (2) outcomes of data related to key factors affecting placement supply and demand; and (3) qualitative perspectives from management, workforce and university stakeholders on placement sustainability. Methods This study reviewed clinical placement, staff full-time equivalent numbers, university program and student cohort data for five allied health professions from 2013 to 2016. In addition, qualitative response data from key stakeholder surveys was analysed thematically. Results In the study period, the rate of growth in placement offers did not match that of university program student numbers and full-time equivalent staff numbers. All stakeholders agreed that sustaining placement provision is enabled by collaboration, continuation of management support for dedicated clinical education staff, a focus on clinical education capacity building activities, outcome data reporting and statewide profession-specific governance, including leadership positions. Collaborations and networks across health and education sectors were reported to enhance efficiency, minimise duplication, streamline communication and support information and resource sharing within and across professions and stakeholders, ultimately sustaining placement provision. Identified barriers to sustainability centred on resourcing and the continued increasing demand for placements. Conclusion Sustaining pre-entry student placements requires stakeholder flexibility and responsiveness and is underpinned by collaboration, information and resource sharing. Dedicated clinical education positions were highly valued and seen as a key contributor to placement sustainability. What is known about the topic? The increasing demand for student placements and strategies used to enhance placement capacity are well known. To date, there have been limited studies investigating cross-sectoral trends and health service enablers and barriers to sustaining responses to placement demand. What does this paper add? This paper describes outcomes of a clinical placement capacity building initiative within public health services, developed from a unique opportunity to provide funding through an industrial agreement. It presents key allied health staff and university partner perspectives on enablers to sustaining placement supply in an environment of increasing placement demand. What are the implications for practitioners? This paper demonstrates that key enablers for the sustainability of placement provision are collaboration between university and health sectors, continuation of management support for dedicated clinical education staff, outcome data reporting and statewide profession-specific governance and leadership. It supports current practices of profession-specific and interprofessional clinical education resource and strategy development and the sharing of expertise for sustained placement provision.

Teaching the principles of safe prescribing to a mixed profession postgraduate cohort: program development

Background

Prescribing medicines is a complex task. A robust prerequisite curriculum that enables the efficient and consistent training of safe and effective prescribers is important. Despite differing prescribing contexts and professional attributes, the core elements of safe and effective prescribing relevant to all prescribers can be identified. This article describes the development process and content of a training program for safe prescribing, which was designed for a mixed cohort of allied health professionals in Queensland, Australia.

Methods

The allied health prescribing training program was designed to align with national standards for prescribing and competencies for safe prescribing. International training programs, for nonmedical prescribing, were examined to inform the program development. Content was delivered by experienced prescribers from a range of professions. The inaugural cohort was surveyed before and after training to ascertain their confidence to prescribe.

Results

A training program for allied health prescribers was developed and delivered to enable the implementation of a state-sponsored research trial in Queensland public facilities. The program consisted of two modules (the second of which is described in this article) complemented by a mandatory period of supervised workplace learning. Remote blended learning, comprising online prerecorded lectures, self-directed learning, teleconference seminars, and a 2-day on-campus intensive residential, was used to deliver content. A total of 19 allied health professionals (12 physiotherapists and 7 pharmacists) completed the program that equipped them to begin a prescribing trial within their specific practice settings. Post module completion, 90% of the cohort felt confident to prescribe for patients in their practice area.

Conclusion

Program development and delivery were challenging, requiring attention to both the needs of each profession and those of the individual practitioner who was required to apply generic prescribing principles to their specific practice setting. Further refinement of content, delivery, assessment, and resource allocation is required for future cohorts.

Do patients discharged from advanced practice physiotherapy-led clinics re-present to specialist medical services?

Objective The aim of the present study was to determine the rates of re-referral to specialist out-patient clinics for patients previously managed and discharged from an advanced practice physiotherapy-led service in three metropolitan hospitals. Methods A retrospective audit was undertaken of 462 patient cases with non-urgent musculoskeletal conditions discharged between 1 April 2014 and 30 March 2015 from three metropolitan hospitals. These patients had been discharged from the physiotherapy-led service without requiring specialist medical review. Rates and patterns of re-referral to specialist orthopaedic, neurosurgical, chronic pain, or rheumatology services within 12 months of discharge were investigated. Results Forty-six of the 462 patients (10.0%) who were managed by the physiotherapy-led service were re-referred to specialist medical orthopaedic, neurosurgical, chronic pain or rheumatology departments within 12 months of discharge. Only 22 of these patients (4.8%) were re-referred for the same condition as managed previously and discharged. Conclusions Ninety-five per cent of patients with non-urgent musculoskeletal conditions managed by an advanced practice physiotherapy-led service at three metropolitan hospitals did not re-present to access public specialist medical services for the same condition within 12 months of discharge. This is the first time that re-presentation rates have been reported for patients managed in advanced practice physiotherapy services and the findings support the effectiveness of these models of care in managing demand for speciality out-patient services. What is known about the topic? Advanced practice physiotherapy-led services have been implemented to address the needs of patients referred with non-urgent musculoskeletal conditions to hospital specialist out-patient services. Although this model is widely used in Australia, there has been very little information about whether patients managed in these services subsequently re-present for further specialist medical care. What does this paper add? This paper identifies that the majority (95%) of patients managed by an advanced practice physiotherapy-led service did not re-present for further medical care for the same condition within 12 months of discharge. What are the implications for practitioners? This paper supports the use of advanced practice physiotherapy-led services in the management of overburdened neurosurgical and orthopaedic specialist out-patient waiting lists.

Pre-entry student clinical placement demand: can it be met?

Objectives The Clinical Education Workload Management Initiative (the Initiative) is a unique, multiprofessional, jurisdiction-wide approach and reform process enshrined within an industrial agreement. The Initiative enabled significant investment in allied health clinical education across Queensland public health services to address the workload associated with providing pre-entry clinical placements. This paper describes the outcomes of a quality review activity to measure the impact of the Initiative on placement capacity and workload management for five allied health professions. Data related to several key factors impacting on placement supply and demand in addition to qualitative perspectives from workforce surveys are reported. Methods Data from a range of quality review actions including collated placement activity data, and workforce and student cohort statistics were appraised. Stakeholder perspectives reported in surveys were analysed for emerging themes. Results Placement offers showed an upward trend in the context of increased university program and student numbers and in contrast with a downward trend in full-time equivalent (FTE) staff numbers. Initiative-funded positions were identified as a major factor in individual practitioners taking more students, and staff and managers valued the Initiative-funded positions’ support before and during placements, in the coordination of placements, and in building partnerships with universities. Conclusions The Initiative enabled a co-ordinated response to meeting placement demand and enhanced collaborations between the health and education sectors. Sustaining pre-entry student placement provision remains a challenge for the future. What is known about the topic? The literature clearly identifies factors impacting on increasing demand for clinical placements and a range of strategies to increase clinical placement capacity. However, reported initiatives have mostly been ad hoc or reactive responses, often isolated within services or professions. What does this paper add? This paper describes implementation of a clinical placement capacity building initiative within public sector health services developed from a unique opportunity to provide funding through an industrial agreement. The Initiative aimed to address the workload associated with clinical education of pre-entry students and new graduates. What are the implications for practitioners? This paper demonstrates that systematic commitment to, and funding of, clinical education across a jurisdiction’s public health services is able to increase placement capacity, even when staffing numbers are in decline.

Spinal anaesthesia--early Australian experience

Australia in 1902 was a fledgling colony in its second year of Federation with a population of around 3.7 million. European settlement had been largely confined to the coastal margins of this enormous land mass, although some bold adventurers in search of gold and farmland had struggled their way into the interior Horsham, situated 300 km northwest of Melbourne in the state of Victoria, was founded in June 1849. By 1902 the town, with a population of around 2500, had grown to boast a hospital, two doctors, a pharmacist and a dentist. It was at the Horsham Hospital on January 7, 1902 that Dr Robert Ritchie performed Australia's first recorded spinal anaesthetic. Ritchie performed a lumbar puncture at the L3-4 level, injected 2 ml of 2% cocaine solution and waited for a total of 20 minutes before realising that the sensation the patient was feeling when he pinched him was pressure, not pain. The 78-year-old man with a gangrenous right leg, prostatic obstruction and congestive cardiac failure was laid supine, and had his right leg amputated through the thigh while being administered brandy and water Strychnine injections were administered four hourly postoperatively. The adoption of the technique of spinal anaesthesia spread quickly in Australia despite communication difficulties at that time.

Onset and offset pharmacodynamics of propofol

Propofol whole blood and plasma concentrations at offset of hypnosis in eighteen patients were inversely related to patient age and body fat. The relationship between propofol concentrations and body fat is derived from the relationship between age and body fat and age was the single independent predictor of concentrations at offset of propofol hypnosis.

Detection of HIV-1 DNA and messenger RNA in individual cells by PCR-driven in situ hybridization and flow cytometry

Human immunodeficiency virus type-1 (HIV-1) DNA and messenger RNA sequences in both cell lines and blood obtained directly from HIV-1-infected patients were amplified by polymerase chain reaction and hybridized to fluorescein-labeled probes in situ, and the individually labeled cells were analyzed by flow cytometry. After flow cytometric analysis, heterogeneous cell populations were reproducibly resolved into HIV-1-positive and -negative distributions. Fluorescence microscopy showed that the cellular morphology was preserved and intracellular localization of amplified product DNA was maintained. Retention of nonspecific probe was not observed. Analysis of proviral DNA and viral messenger RNA in cells in the blood of HIV-1-infected patients showed that the HIV-1 genome persists in a large reservoir of latently infected cells. With the use of this technique it is now possible to detect single-copy DNA or low-abundance messenger RNA rapidly and reproducibly in a minor subpopulation of cells in suspension at single-cell resolution and to sort those cells for further characterization.

Application of automated DNA sizing technology for genotyping microsatellite loci

Highly polymorphic microsatellite loci offer great promise for gene mapping studies, but fulfillment of this potential will require substantial improvements in methods for accurate and efficient genotyping. Here, we report a genotyping method based on fluorescently labeled PCR primers and size characterization of PCR products using an automated DNA fragment analyzer. We capitalize on the availability of three distinct fluorescent dyes to label uniquely loci that overlap in size, and this innovation increases by threefold the number of loci that can be analyzed simultaneously. We label size standards with a fourth dye and combine these with the microsatellite PCR products in each gel lane. Computer programs provide very rapid and accurate sizing of microsatellite alleles and efficient data management. In addition, fluorescence signals are linear over a much greater range of intensity than conventional autoradiography. This facilitates multiplexing of loci (since signal intensities often vary greatly) and helps distinguish major peaks from artifacts, thereby improving genotyping accuracy.

Ketamine, midazolam and vecuronium infusion. Anaesthesia for Down's syndrome and congenital heart disease

A ketamine, midazolam and vecuronium infusion was used for total intravenous anesthesia in a patient with Down's syndrome, a ventricular septal defect and pulmonary hypertension. A mixture of ketamine 200 mg, midazolam 5 mg and vecuronium 12 mg in 50 ml of normal saline was infused at 0.5 ml/kg/hour. This simple technique and ventilation with 100% oxygen maintained tissue oxygenation and cardiovascular stability.

Automation of specific human gene detection

An instrument/chemistry system is described that automates a new chemical procedure functionally equivalent to Southern blotting. A fluorescence gel scanner that detects migrating DNA fragments in real-time analyzes the samples produced by a prototype liquid-handling instrument that automates a solution-phase hybridization/solid-phase capture chemistry for DNA analysis. The combination of this chemistry, the gel scanner, and robotic automation eliminates the tedium encountered in traditional manual methods for specific gene detection and reduces analysis time from days to hours. Restriction fragment lengths are measured with high precision by comparison with in-lane standards to minimize effects attributable to migration anomalies. The utility of this automated system is demonstrated by executing a clinical research application involving hybridization to a multi-copy repeat sequence on the Y chromosome and its detection.

Automation of specific human gene detection

An instrument/chemistry system is described that automates a new chemical procedure functionally equivalent to Southern blotting. A fluorescence gel scanner that detects migrating DNA fragments in real-time analyzes the samples produced by a prototype liquid-handling instrument that automates a solution-phase hybridization/solid-phase capture chemistry for DNA analysis. The combination of this chemistry, the gel scanner, and robotic automation eliminates the tedium encountered in traditional manual methods for specific gene detection and reduces analysis time from days to hours. Restriction fragment lengths are measured with high precision by comparison with in-lane standards to minimize effects attributable to migration anomalies. The utility of this automated system is demonstrated by executing a clinical research application involving hybridization to a multi-copy repeat sequence on the Y chromosome and its detection.

Automated DNA sequencing methods involving polymerase chain reaction

Polymerase chain reaction (PCR) as a method for preparing DNA templates has been used for several DNA sequencing applications. An in situ procedure for directly sequencing PCR products by the dideoxy-termination method has been developed by using fluorophore-labeled sequencing primers. Completed sequence reactions were combined and loaded into a single electrophoretic lane of a fluorescence-based DNA sequence analyzer. DNA targets devoid of a universal primer sequence could be sequenced with labeled universal primers by incorporating a universal primer sequence into the PCR product. With this method, the sequence of a 351-bp region in the bacteriophage lambda genome was fully analyzed in a single lane with automatic base identification accuracy of greater than 99%. An unknown sequence, 1.7 kb long, also was sequenced by this procedure, in combination with a "PCR gene walking" strategy. Comparison of the 1110 bases in overlapping sequence data from both strands yielded only two single-base ambiguities. Automated DNA sequence analysis of the highly polymorphic HLA-DQA-1 (alpha) region in the human genome can be performed with this simple methodology. Use of this PCR-sequencing method to analyze DNA extracted from a one-month-old blood sample from an individual who is heterozygous at this locus allowed unambiguous assignment of genotype.

Automated DNA sequencing methods involving polymerase chain reaction

Polymerase chain reaction (PCR) as a method for preparing DNA templates has been used for several DNA sequencing applications. An in situ procedure for directly sequencing PCR products by the dideoxy-termination method has been developed by using fluorophore-labeled sequencing primers. Completed sequence reactions were combined and loaded into a single electrophoretic lane of a fluorescence-based DNA sequence analyzer. DNA targets devoid of a universal primer sequence could be sequenced with labeled universal primers by incorporating a universal primer sequence into the PCR product. With this method, the sequence of a 351-bp region in the bacteriophage lambda genome was fully analyzed in a single lane with automatic base identification accuracy of greater than 99%. An unknown sequence, 1.7 kb long, also was sequenced by this procedure, in combination with a "PCR gene walking" strategy. Comparison of the 1110 bases in overlapping sequence data from both strands yielded only two single-base ambiguities. Automated DNA sequence analysis of the highly polymorphic HLA-DQA-1 (alpha) region in the human genome can be performed with this simple methodology. Use of this PCR-sequencing method to analyze DNA extracted from a one-month-old blood sample from an individual who is heterozygous at this locus allowed unambiguous assignment of genotype.

Identification of mutations leading to the Lesch-Nyhan syndrome by automated direct DNA sequencing of in vitro amplified cDNA

The Lesch-Nyhan (LN) syndrome is a severe X chromosome-linked disease that results from a deficiency of the purine salvage enzyme hypoxanthine phosphoribosyltransferase (HPRT). The mutations leading to the disease are heterogeneous and frequently arise as de novo events. We have identified nucleotide alterations in 15 independently arising HPRT-deficiency cases by direct DNA sequencing of in vitro amplified HPRT cDNA. We also demonstrate that the direct DNA sequence analysis can be automated, further simplifying the detection of new mutations at this locus. The mutations include DNA base substitutions, small DNA deletions, a single DNA base insertion, and errors in RNA splicing. The application of these procedures allows DNA diagnosis and carrier identification by the direct detection of the mutant alleles within individual families affected by LN.

High-performance liquid chromatographic analysis of oligodeoxyribonucleotide base composition

A significantly improved method for base composition analysis of synthetic oligodeoxyribonucleotides is presented. This highly accurate and sensitive method used enzymatic digestion followed by high-resolution HPLC of the nucleosides to determine the empirical base composition of the parent compound. The enzymatic digestion reaction is quantitative and is not blocked by modified bases, thus allowing the degree of base deprotection and chemical modification to be assessed. Digestion data are presented for oligodeoxyribonucleotides which range from 18 to 150 bases in length with excellent agreement of experimental and theoretical composition. The method is also applicable to high-molecular-weight genomic DNA.

Two stage maxillary canine transplantation

Two case reports are described in which the two stage canine transplantation technique was found to be necessary in order to undertake orthodontic tooth movements in preparation of the transplantation sites.

Traction--a surgical/orthodontic procedure

Maxillary crowding may cause failure of eruption of the canine. The teeth so displaced are directed buccally or palatally. In both cases, surgical intervention is indicated after space has been made in the arch. Palatally displaced canines are treated by surgical excision of palatal mucosa to promote eruption. Wide excision is indicated to prevent the healing process from covering the exposed tooth crown. Because of the anatomy of the buccal mucosa, however, surgical excision of the crowns of buccally displaced canine frequently results in periodontal problems. An alternative technique is therefore presented; this involves the surgical exposure of the crowns of buccally displaced teeth to allow the attachment of a wire traction hook. The crown is then recovered. The traction hook provides a point of attachment, so that orthodontic forces may be applied to the unerupted tooth to guide its eruption. The preservation of the mucosal flap ensures a normal epithelial attachment develops on the buccal surface of the tooth, and the normal gingival anatomy of the buccal mucosa is maintained. The procedure may also be used in cases where upper incisors have been prevented from erupting because of the presence of supernumerary teeth. Even after surgical removal of the supernumerary teeth, the permanent incisors often fail to erupt. In such cases, the placement of traction hooks will enable the orthodontist to bring the unerupted teeth into their correct positions in the arch.

The eruption of lower third molars following the loss of lower second molars: a longitudinal cephalometric study

In the orthodontic assessment of mild malocclusion of the lower arch, the impaction of lower third molars is often ignored. In such cases lower arch alignment is frequently, later, compromised by the continued presence of the impacted third molars. The authors have produced a simple geometric procedure, to be applied to rotated cephalograms, which will enable clinicians to forecast accurately those lower third molars which will reach occlusion, after the extraction of lower second molars. In addition, such extractions will correct mild buccal arch crowding without the use of appliances. Results of the eruptive progress of 50 lower third molars, over a 7 year period, are presented to support the theory.