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Abstract: Aim: This paper reports on the findings from 6 focus groups conducted with Australian medical students. The focus groups sought students' perspectives on how the influence of commercial interests on medical practice and education could be managed. Method: We conducted 6 focus groups with medical students in New South Wales, Australia. Participants were recruited via student‐run medical society and faculty e‐mail lists. Forty‐nine students from 6 medical schools in New South Wales participated. The research team reflected on the extent to which students uncritically appealed to science in the abstract as a management solution for conflicts of interest. Data analysis was largely inductive, looking for uses of scientific terminology, EBM, and appeals to “science” in the management of COI and applied theoretical analyses of scientism. Results: The students in our study suggested that science and evidence‐based medicine, rather than ethics or professionalism, were the best tools to deal with undue influence and bias. This paper uses philosophy of science literature to critically examine these scientistic appeals to science and EBM as a means of managing the influence of pharmaceutical reps and commercial interests. We argue that a scientistic style of reasoning is reinforced through medical curricula and that students need to be made aware of the epistemological assumptions that underpin science, medicine, and EBM to address the ethical challenges associated with commercialised health care. Conclusion: More work is needed to structure medical curricula to reflect the complexities of practice and realities of science. However, curricula change alone will not sufficiently address issues associated with commercial interests in medicine. For real change to occur, there needs to be a broader social and professional debate about the ways in which medicine and industry interact, and structural changes that restrict or mitigate commercial influences in educational, research, and policy settings. [ABSTRACT FROM AUTHOR]

Governments around the world are looking at means to improve health care services and health outcomes for their communities within a sustainable expenditure framework. There is a general agreement that strengthening primary health care is the way for the future. Primary health care organizations (PHCOs) are seen as a means to achieving more effective and efficient health care. This paper proposes a complex adaptive framework for PHCOs, taking account of health and illness being subjective experiences, health care being 'whole person'-focused, and PHCOs focusing on all of a community's health determinants and community-based health care needs. Such approach would foster building healthy local communities as much as seamless integration of health services for all. However, despite the expressed intensions towards patient-centred health care reform the bureaucratic mindset of Australian health policy makers risks true reform by imposing highly structured - rather than 'simple'- policy and operational rules. [ABSTRACT FROM AUTHOR]

Introduction National guidelines for prevention of cardiovascular disease make different recommendations in relation to screening and treating patients with aspirin, antihypertensive treatment and statins. The resource cost and health implications of these differences are quantified in this paper. Data sources Guidelines were obtained from Australia, New Zealand, Canada, UK and USA. Effectiveness data were obtained from published sources, costs and a model population of 2000 patients from US sources. Method The resource costs and health effects of screening and treating a standard population of 2000 persons were determined for each of the five national guidelines. Costs and effects were calculated over a 5-year time horizon and cost-effectiveness determined cost per cardiovascular event prevented. Results Cost per cardiovascular event prevented is lowest in older patients and very high under 35. The New Zealand guidelines are more cost-effective of the national guidelines, however, they would be more effective if they incorporated US recommendations on the use of aspirin. Further antihypertensive treatment is the least cost-effective of the interventions considered. Discussion Cardiovascular disease prevention guidelines should focus on older rather than younger patients. Treatment eligibility should be informed more by risk than by individual risk factor status. Guidelines should put greater emphasis on the use of aspirin and initial antihypertensive treatment than on achieving blood pressure targets. Conclusion In order to justify their recommendations guidelines should quantify the resource implications in relation to the health benefits. [ABSTRACT FROM AUTHOR]

Objectives: To identify outcome measures used to evaluate performance of healthcare professional role substitution against usual medical doctor or specialist medical doctor care to facilitate our understanding of the adequacy of these measures in assessing quality of healthcare delivery. Methods: Using a systematic approach, we searched Medline, Cochrane Central Register of Controlled Trials, Embase, CINAHL, and Web of Science from database inception until May 2020. Studies that presented original comparative data on at least one outcome measure were included following screening by two authors. Findings were synthesized, and outcome measures classified into six domains which included: effectiveness, safety, appropriateness, access, continuity of care, efficiency, and sustainability which were informed by the Institute of Medicine dimensions of healthcare quality, the Australian health performance framework, and Levesque and Sutherland's integrated performance measurement framework. Results: One thirty five articles met the inclusion criteria, describing 58 separate outcome measures. Safety of role substitution models of care was assessed in 80 studies, effectiveness (n = 60), appropriateness (n = 40), access (n = 36), continuity of care (n = 6), efficiency and productivity (n = 45). Two‐thirds of the studies that assessed productivity and efficiency performed an economic analysis (n = 27). The quality and rigour of evaluations varied substantially across studies, with two‐thirds of all studies measuring and reporting outcomes from only one or two of these domains. Conclusions: There are a growing number of studies measuring the performance of non‐medical healthcare professional substitution roles. Few have been subject to robust evaluations, and there is limited evidence on the scientific rigour and adequacy of outcomes measured. A systematic and coordinated approach is required to support healthcare settings in assessing the value of non‐medical role substitution healthcare delivery models. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Time series analysis has seen limited application in the biomedical Literature. The utility of conventional and advanced time series estimators was explored for intensive care unit (ICU) outcome series. Monthly mean time series, 1993-2006, for hospital mortality, severity-of-illness score (APACHE III), ventilation fraction and patient type (medical and surgical), were generated from the Australia and New Zealand Intensive Care Society adult patient database. Analyses encompassed geographical seasonal mortality patterns, series structural time changes, mortality series volatility using autoregressive moving average and Generalized Autoregressive Conditional Heteroscedasticity models in which predicted variances are updated adaptively, and bivariate and multivariate (vector error correction models) cointegrating relationships between series. The mortality series exhibited marked seasonality, declining mortality trend and substantial autocorrelation beyond 24 lags. Mortality increased in winter months (July-August); the medical series featured annual cycling, whereas the surgical demonstrated long and short (3-4 months) cycling. Series structural breaks were apparent in January 1995 and December 2002. The covariance stationary first-differenced mortality series was consistent with a seasonal autoregressive moving average process; the observed conditional-variance volatility (1993-1995) and residual Autoregressive Conditional Heteroscedasticity effects entailed a Generalized Autoregressive Conditional Heteroscedasticity model, preferred by information criterion and mean model forecast performance. Bivariate cointegration, indicating long-term equilibrium relationships, was established between mortality and severity-of-illness scores at the database level and for categories of ICUs. Multivariate cointegration was demonstrated for {log APACHE III score, log ICU length of stay, ICU mortality and ventilation fraction}. A system approach to understanding series time-dependence may be established using conventional and advanced econometric time series estimators. [ABSTRACT FROM AUTHOR]

Rationale Transfer of training (ToT) is defined as the application of competencies acquired during training into the workplace. Poor ToT to clinical practice in mental health settings has negative implications for evidence-based service provision. Aims and objectives This study aimed to explore the variables influencing differences in ToT across mental health settings. Variables of interest included organization type, caseload and several variables related to the opportunity to use training. Method One hundred and seventy-three mental health clinicians from community-based governmental and non-governmental mental health services in eastern Australia were trained in recovery-oriented interventions. Measures of ToT included time taken until implementation of intervention protocols, assessed using a clinical audit and a questionnaire survey completed by clinicians to identify barriers to implementation 6 months after training. Results Approximately 37% of the trained clinicians participating in the study were found to be implementing training protocols in clinical practice. In addition, the average time taken to implement the protocols was 5.6 months following training. The most frequently cited barriers were institutional constraints. Higher caseloads and more frequent client contact were related to a higher level of ToT. Conclusion ToT can be difficult to achieve in clinical practice. Greater facilitation of ToT may be achieved through better integration of the new ideology and protocols, regular monitoring of progress, staff incentives and examination of external attributions by clinicians of their responsibility to transfer training. [ABSTRACT FROM AUTHOR]

Rationale To describe the first phase of a global evaluation framework for the National Prescribing Service (NPS), with a focus on services for health professionals, and in particular highlight the lessons learnt from evaluation around the establishment and implementation of this national pragram. Methods The agreed evaluation framework used mixed methods focused around a series of evaluation questions, aimed at measuring the overall effect of this new organization as well as the individual pragrams within it. The evaluation questions were determined a priori and were based on the objectives established by the organization in its first year of operation. A detailed analyses has been completed of: the process, scope and reach of pragram delivery using both quantitative and qualitative measures; changes in attitudes and knowledge measured through key informant interviews and surveys of professional groups and consumers; and changes in prescribing behaviour and savings to the Pharmaceutical Benefits Scheme (PBS) through analysis of prescription data. The evaluation period for this report was mid-1998 to mid-2004. Results The NPS has successfully implemented a complex, multi-facted pragram across Australia. From 1998 to 2004, in addition to print material provided to all general practitioners (GPs) and pharmacists, 90% of all GPs have been actively involved in one or more educational activity; 116 of 120 divisions of general practice have coordinated local NPS pragrams; and 9% of pharmacists have actively participated in at least one educational activity. Sixty per cent of GPs and pharmacists rated the printed educational materials as good or very good. In the last three years, the NPS activities have generated savings in the range of $121–163 million to the PBS, owing to changes in prescribing practices. Conclusion The national evaluation framework has informed pragram delivery and ongoing design and development. Continued refinement of existing evaluation methods and further exploration of new techniques will remain a priority for the organization. [ABSTRACT FROM AUTHOR]