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Millions of Australians use the private health system every year. They should receive safe, high-quality, value-based care. However, poor policy and inadequate regulation of medical technology is driving low-value care at great expense to consumers and the broader health system. Key drivers include the Prescribed List of Medical Devices and Human Tissue, gaps in quality and safety controls for devices being used, and marketing and conflicts of interest. All of these should be addressed to reduce low-value care in Australia's private health system, so consumers are protected from harm and limited health budgets are used effectively. What is known about the topic? With health expenditure rising unsustainably, there is a growing focus on ways to reduce low-value care to improve health outcomes and eliminate unnecessary costs. What does this paper add? This paper details drivers of low-value care in Australia's private health system and recommendations to overcome them. Drivers include the Prescribed List of Medical Devices, gaps in safety and quality controls, and conflicts of interest and marketing. What are the implications for practitioners? These insights are relevant to clinicians, researchers, policymakers, consumers and health business leaders with an interest in low-value care. This article belongs to the Special Issue: Value-based Healthcare. [ABSTRACT FROM AUTHOR]

Value based healthcare beyond the clinical domain is the focus of this case study. We share NSW Health's experiences in achieving value through a focus on outcomes in non-clinical and clinical support services using examples that demonstrate key aspects across the commissioning cycle. These include: the importance of stakeholder engagement in the planning phase to later success; the critical role of non-clinical services in patient experience; the opportunity to facilitate value by introducing new approaches in business areas such as procurement; and the role of clinical supports such as digital enablement to facilitate outcome-focussed clinical models. Applying a value lens to non-clinical services can increase the potential benefits to patients, clinicians and the system. What is known about the topic? Value based healthcare is a way of making transparent and equitable decisions about resource allocation to deliver better outcomes for individuals, health services and the system. What does this paper add? This paper reflects on the opportunity to deliver value based healthcare beyond clinical models of care, including in non-clinical and clinical support services, using a commissioning approach. What are the implications for practitioners? The learnings shared through the case studies presented can be applied by practitioners to their own projects to support value based approaches across all aspects of health care. This article belongs to the Special Issue: Value-based Healthcare. [ABSTRACT FROM AUTHOR]

Allied health services in rural and remote hospitals often work in siloed and solo discipline-specific positions. They are often part of general multi-disciplinary teams without a clearly articulated service model that integrates care for individuals and addresses broader community health needs. Integrated care service models for clients with complex disabilities or chronic health needs have demonstrated improved outcomes, but feasible service models are rarely described in the context of rural, remote and Aboriginal and Torres Strait Islander communities. Integration can support primary health care in remote communities where resources are thin, and the breadth of multidisciplinary service providers is not available. A remote health service, in collaboration with a University Department of Rural Health and community partners, developed a community rehabilitation and lifestyle service for adults who experience chronic disease, disability or were at risk of functional decline due to frailty. Using an integrated approach, this model of care improves access to specialist and primary healthcare services, delivers targeted group-based rehabilitation and preventative activities, and addresses community and workforce capacity to meet the needs of the remote community. This paper describes a remote primary health care, Integrated Allied Health Service Model, developed with a focus on the co-ordination and integration of care and resources between the health service, education and community. Remote communities require primary care services that are inclusive of allied health and can be responsive to individual and community needs. Services require a workforce and a service model that can be creative and flexible. The Service described, delivered both a novel service model that complemented the primary care services already being delivered, and focused on workforce and community capacity building. [ABSTRACT FROM AUTHOR]

Evidence indicates that general practice-based multidisciplinary teams can offer a means of addressing some of the key issues currently facing Western health systems, especially workforce and chronic disease management. Elements of team-working have been addressed in research and policy initiatives both overseas and in Australia, yet some important aspects of primary health care multidisciplinary team-working still remain unclear in the Australian context. This discussion paper has been developed by the Australian General Practice Network (AGPN) to raise awareness of and promote thought on four questions relating to multidisciplinary team-working that AGPN considers important but that, as yet, have not been fully addressed. (Except where indicated, it is not a position statement about AGPN's views on this matter.) Questions considered are: Who is in the team? What makes a successful team? How should teams be funded in Australia? Who coordinates the team? Each question broadly considers what is already known about the area through purposeful literature reviews of the published and grey literature, current policy impacting on the area, and suggested areas for policy development in the context of Australian general practice and primary care. [ABSTRACT FROM AUTHOR]

This paper examines the implications of the second sentence in Tudor Harts statement about inverse care – that its operation was strongest when exposed to market forces. In the Australian context, we briefly review some available evidence for inverse care in three groups – Aboriginal and Torres Strait Islander people and those living in remote and socioeconomically disadvantaged areas. We then discuss the extent to which these examples can be attributed to the operation of supply-and-demand within Australia's hybrid fee-for-service system in general practice. Our analysis suggests disparities in workforce supply and the ability of disadvantaged groups to seek preventive and proactive care are critical factors. These, in turn, suggest the need to fund general practice to be responsible for proactive and preventive care of disadvantaged population groups alongside broader structural reforms in workforce, education and taxation. This paper examines the implications of the second sentence in Tudor Harts statement about inverse care – that its operation was strongest when exposed to market forces. Examples of inverse care can be found in the disparities access to primary health care in Australia, which can be attributed to both supply-and-demand factors in Australia's hybrid market model of health care. Correcting these requires changes to the funding and workforce models, as well as specific actions at the service and community level. [ABSTRACT FROM AUTHOR]

Chronic disease identification and management is a significant issue in Australia, with general practice being the primary contact point for those at risk of, or living with, chronic disease. However, there is a well-described gap between guideline recommendations for chronic disease management and translation in the general practice setting. In 2018, a group of researchers, clinicians and software developers collaborated to develop a tool to support the identification and management of chronic disease in general practice, with the aim to create a platform that met the needs of general practice. The co-design process drew together core principles and expectations for the establishment of a technological platform, called Future Health Today (FHT), which would sit alongside the electronic medical record (EMR) management system within general practice. FHT used algorithms applied to EMR data to identify patients with, or at risk of, chronic disease and requiring review. Using chronic kidney disease as a clinical focus, the FHT prototype was piloted in a large, metropolitan general practice, and a large regional general practice. Based on user feedback, the prototype was further developed and improved. This paper provides a report on the key features and functionalities that participants identified and implemented in practice. Future Health Today is a new platform, co-designed by general practice for general practice, which aims to streamline the identification and management of chronic disease to improve health outcomes. This paper describes the development of the technology platform and how it was optimised through an implementation study in general practice. [ABSTRACT FROM AUTHOR]

Digital health technologies are a proposed solution to improve healthcare delivery and reduce pressures on the healthcare system, but these technologies are new to much of the health workforce. This perspective paper highlights lessons learned from the global experience of rapid digital transformation of health workforces, including fostering a culture of learning, ensuring accreditation and recognition, and adopting a transdisciplinary approach. Evidence-based actions are proposed to address recommendations to (i) ensure foundational workforce digital health capability and (2) build specialist digital health career pathways. Australia must take a national approach and strategically leverage strong collaborations across sectors including healthcare, education and government to ensure a consistent, regulated and sustainable digital workforce capability. [ABSTRACT FROM AUTHOR]

Objective: The coronavirus disease 2019 (COVID-19) pandemic precipitated a major shift in the use of telehealth in Australia. The changes highlighted gaps in our knowledge regarding the efficacy of, and clinician attitudes to, the use of telehealth. The current study expands and deepens the available evidence as a result of being collected in unique circumstances that removed one of the major barriers (lack of Medicare rebates) and also one major enablers (willingness) of telehealth uptake. Methods: Using a semi-structured interview, we invited clinicians (N = 39) to share their perspectives, attitudes and experiences of using telehealth. Topics covered included perceptions of the strengths and challenges of telehealth, and how experience of using telehealth during the COVID-19 pandemic had influenced clinicians' views and intentions regarding their future practice. Participants included clinicians from five disciplines across public and private practice: paediatrics, neurology, immunology, rural general practice, and orthopaedics. Results: We found three key dimensions for consideration when assessing the suitability of telehealth for ongoing practice: the attributes of the patient population, the attributes of the clinical context and environment, and the risks and benefits of a telehealth approach. These findings map to the existing literature and allow us to infer that the experiences of clinicians who previously would have chosen telehealth did not differ significantly from those of our 'pandemic-conscripted' clinicians. Conclusions: Our findings map clearly to the existing literature and allow us to infer that the experiences of the clinicians who have chosen telehealth (and are already represented in the literature) did not differ significantly from those trying out telehealth under the unique circumstances of the removal of the Medicare Benefits Scheme barrier and external pressure that over-rides the 'willingness' enabling factor in uptake decisions. What is known about the topic? Clinician and patient experiences of telehealth use have already been documented in contexts where both clinician and patient have opted-in to that process. What does this paper add? The paper adds data on clinician experience across a range of specialities, from a context (pandemic public-heath measures) where the choice element was reduced for both patient and clinician. What are the implications for practitioners? The data speak to the generalisability of existing evidence, but also provide practical considerations in planning for the inclusion of telehealth for specialist health services in the Australian context. [ABSTRACT FROM AUTHOR]

Objective: This study set out to present data on out-of-pocket payments for Medicare mental health services provided by general practitioners (GP), psychiatrists, clinical psychologists and other psychologists, to explore how much is spent on out-of-pocket payments for mental health; if any trends could be seen; and what variations exist across regions. Methods: We performed secondary analysis of publicly available data on Medicare-subsidised GP, allied health and specialist health care across Australia. We merged and interrogated data covering the period 2013–19 and 2019–21 to create a data set covering eight full years of Medicare mental health services, arranged by profession and by region. Results: Out-of-pocket payments for mental health care in Australia have been rising consistently over the period 2013–21, at a considerably faster rate than overall expenditure on mental health care. There is wide variation in out-of-pocket payments depending on where you live. Conclusions: The impact of out-of-pocket payments on community access to mental health care is growing. This has implications, especially in poorer communities, for access to care. This should be an important consideration taken as the Australian Government considers next steps in national mental health reform, including the Better Access Program, currently under evaluation. What is known about the topic? A$35 m is spent on Medicare mental health services every week but there has been little research on the out-of-pocket payments charged to Australians. What does this paper add? Looking at Medicare data from 2013 to 2021, this paper answers three main questions: how much are out-of-pocket payments for mental health in Australia; what trends can be seen; and what variations exist? What are the implications for practitioners? Medicare's Better Access Program is under current review and this research can help practitioners, funders and policy-makers understand the significant investment made in mental health services. [ABSTRACT FROM AUTHOR]

Diagnostic imaging is increasingly being used in Australia to aid clinician diagnostic and therapeutic decision-making. There is concern that this increased use represents an overconsumption of inappropriate health services, which wastes finite resources and may cause direct or indirect harm to the patient. Australian health policies have primarily focused on increasing patient access to diagnostic imaging. While these policies address inequitable access and may lead to timely diagnosis and improved health outcomes, these benefits have not been weighed against the unintended harms. This perspective article will explore the unintended consequences of increasing access to diagnostic imaging as well as provide potential solutions to improve the effectiveness of policies in this area. What is known about the topic? When warranted, diagnostic imaging aids the diagnostic process by ruling in (or out) conditions that benefit from treatment and lead to improved patient outcomes. What does this paper add? This paper describes recent policies related to diagnostic imaging in Australia, discusses how increasing access may lead to unintended harms and create further inefficiencies in the system, and provides direction for future health policies in this area. What are the implications for practitioners? Addressing the inappropriate use of diagnostic imaging is crucial for the sustainability of the sector. [ABSTRACT FROM AUTHOR]

Objective: Healthcare delivery in Australia is managed at state and territory levels. This paper aims to compare the content and structure of publicly accessible Australian maternity service state and territory frameworks which guide the delivery of maternity care. Methods: A scoping review was conducted to identify publicly accessible Australian state and territory maternity service frameworks. A comparative content analysis was undertaken. Results: Six of the potential eight states and territories had locatable frameworks. Differences in both structure and content were found between frameworks. Variation exists between standalone maternity service frameworks and comprehensive clinical frameworks. Several jurisdictions align policy and ministerial directives in their frameworks outlining service delivery and guidance relating to maternal and/or neonatal transfer. Language referring to the assessment of maternity services and service risk varied. Conclusion: Consistency in structure, language, and a clear communication strategy embedded into each maternity service framework may improve the functioning and consistency of Australian maternity services at each level of the healthcare system. What is known about this topic? Limited evidence or analysis exists of the content of different maternity service framework documents in each Australian state and territory, despite a body of discourse and critical review regarding the previous national maternity service framework. What this paper adds? Similarities and differences in Australian maternity service frameworks are examined, providing insights into maternity operations and prioritised policy across differing jurisdictions. What are the implications for practitioners? Analysis of Australian maternity service frameworks highlights opportunities where jurisdictional governance documents can be strengthened or unified in the absence of an agreed national maternity service framework. [ABSTRACT FROM AUTHOR]

Objective: To explain how the Primary Health Network commissioning model works, and factors likely to affect its success. Methods: The study focuses on the delivery of primary healthcare services by one Primary Health Network (PHN) in Australia. The qualitative case study is informed by a desk top review, interviews (n = 49) and observations with key stakeholders involved in commissioning and delivering primary healthcare services in the region. Results: The study provides several insights about the PHN model. First, conceptually, the PHN commissioning model is well suited to identifying and meeting local primary healthcare priorities, bringing together a range of stakeholders involved in healthcare provision. Second, although primary healthcare services are difficult to specify and measure, PHN staff use their content knowledge and experience, and relationships with providers and the community, to design services that meet the needs of consumers. Third, the success of this model may be undermined by short funding cycles and short lead-times, a focus on national rather than local priorities, and continual reductions in operational funding. This may result in more procedural forms of contract management, which may mean that changes in service need, provision and quality go unnoticed. Conclusions: This study shows that although clever in design, the PHN model may not meet its full potential. Given continual changes to the model, including funding, further independent research should be undertaken to understand how PHNs adjust and whether services continue to meet the needs of the local community. What is known about the topic? Primary Health Networks commission a range of services. Little is known about how the commissioning model works and what enables its success. What does this paper add? While elements of an effective model exist, this paper finds that the its effectiveness is contingent on stability, funding cycles, and sufficient resources to manage contracts. What are the implications for practitioners? This paper identifies the risks to the effective implementation of commissioning and how they may be addressed. [ABSTRACT FROM AUTHOR]

Objectives: To describe the quantity and cost of in-person and telehealth exercise physiology (EP) reimbursed under the Medicare Benefits Schedule (MBS) in Australia before and during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This study uses publicly available MBS data to describe EP services (in-person and telehealth) reimbursed by Medicare between January 2020 and December 2021. Data were extracted at state and national levels. Results: Despite a reduction in quantity and cost in quartile (Q) 2 2020 (41% reduction), MBS-reimbursed EP services have remained relatively constant at a national level through the 2-year observation period. Service claims averaged 88 555 per quarter in 2020 and 95 015 in 2021. The proportion of telehealth consultations relative to total quarterly claims for EP was <1% in Q1 2020, 6.0% in Q2 2020, 2.4% in Q3 2020 and 1.7% in Q4 2020. This dropped to an average of 1.4% across 2021 (Q1–Q4). States undergoing lockdown periods reported decreased service rates relative to February 2020 (i.e. pre-lockdown). EP services were associated with a Medicare expenditure of AUD17.9M in 2020 (telehealth = 2.4% of total) and AUD19.7M (telehealth = 1.5% of total) in 2021. Conclusions: Quantity and cost of MBS-reimbursed EP services remained relatively constant throughout the height of service disruption due to COVID-19 (2020/21). Telehealth uptake during this time has been minimal for EP. What is known about the topic? Telehealth item numbers were introduced to the Medicare Benefits Schedule (MBS – part of Australia's health scheme) in response to the COVID-19 pandemic to facilitate continued access to health services, including exercise physiology (EP). What does this paper add? The uptake of telehealth service modalities has been minimal for EP through 2020–21. What are the implications for practitioners? The minimal uptake telehealth suggests that further research, advocacy and promotion is needed to ensure that telehealth can be a viable option for patients to consider when accessing EP services. [ABSTRACT FROM AUTHOR]

Objectives: This study explored publicly funded health system and patient expenditure in the post-acute phase following discharge from inpatient acquired brain injury (ABI) or spinal cord injury (SCI) rehabilitation. The secondary aim was to explore sociodemographic and injury characteristics associated with high costs. Methods: This was a prospective cohort study. 153 patients (ABI: n = 85; SCI: n = 68) who consented to the use of their Medicare data were recruited between March 2017 and March 2018, at the point of discharge from ABI or SCI specialist rehabilitation units. The main outcome measure involved linkage of the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data for the 12 months following discharge from rehabilitation. Bayesian penalised regression was used to determine characteristics associated with high costs. Results: The median number of MBS items used in the 12 months after discharge was 33 (IQR: 21–52). General practitioners and allied health services were accessed by 100% and 41% of the cohort, respectively. The median MBS system cost (in Australian dollars) was $2006 (IQR: $162–$3090). Almost half (46%) of the participants had no MBS patient expenditure. The median PBS system cost was $541 (IQR: $62–$1574). For people with ABI, having a traumatic injury or one comorbidity was associated with lower PBS system costs by on average $119 and $134, respectively. We also found that hospitalisation in ABI was associated with higher PBS system costs, by on average $669. Conclusion: There was evidence of high and variable MBS and PBS costs, raising concerns about financial hardship. Future research should focus on identifying any unmet service and prescription needs in the post-acute rehabilitation phase for these populations. What is known about the topic? Acquired brain injury and spinal cord injury incur high long-term health costs, yet little is known about Medicare service use and costs in the early post-acute phase. What does this paper add? This study provides insight into service use and the burden of injury on Medicare Benefits Schedule and Pharmaceutical Benefits Scheme systems in the 12 months after hospital discharge. High and variable system and patient expenditure are most notable. What are the implications? Highly variable patient costs raise concerns about the access and affordability of sufficient healthcare services in the post-acute rehabilitation period. [ABSTRACT FROM AUTHOR]

Background: For Aboriginal and Torres Strait Islander women, the premature burden of cardiovascular disease is affecting their capacity to fulfil roles in society, and promote the health and wellbeing of future generations. In Australia, there is limited understanding of the difference in primary preventive cardiovascular care experienced by women, despite knowledge of sex and gender differentials in health profile and receipt of guideline-based acute care. This paper sought to explore the health profile and receipt of assessment and management of cardiovascular risk for Aboriginal and Torres Strait Islander women accessing preventive primary health care, and investigate gender differentials. Method: Records of 1200 current clients, 50% women, aged 18–74 years from three Aboriginal Health Services in central and South Australia for the period 7/2018–6/2020 were reviewed. Results: Twelve percent had documented cardiovascular disease. Compared with men, women with no recorded cardiovascular disease had a greater likelihood of being overweight or obese, a waist circumference indicative of risk, diabetes, and depression. Women were less likely to report being physically active. Conclusions: The research concluded that gaps exist in the provision and recording of guideline-recommended primary preventive care regardless of sex. These are stark, given the evident burden. Variance in cardiovascular risk and disparities in care have been documented for women; however, the knowledge about gaps in care is less explored for sub-populations, such as Indigenous populations. This study explores the health profile and receipt of preventive risk assessment and management in primary health services for Aboriginal and Torres Strait Islander women compared with men, finding women and men alike experience gaps in the provision of care to meet identified health needs. [ABSTRACT FROM AUTHOR]

Objectives: To identify features of mental health services that affect the uptake of services among parents of children with chronic medical conditions, to inform the design of pathways into mental health care. Methods: A discrete choice experiment in which participants made choices between hypothetical mental health services described in terms of service features: cost, wait time, provider knowledge of chronic medical conditions, recommendations, opening hours, and travel time. Participants were parents of children attending The Royal Children's Hospital outpatient clinics for the management of a chronic medical condition who completed the online survey between August 2020 and January 2021. The uptake of mental health services with differing features was predicted based on regression models examining the relationship between choice and service features, and accounting for participant characteristics and unobserved heterogeneity. Results: The sample comprised 112 parents, of whom 52% reported unmet needs. The most influential service features were wait times, cost, recommendation from medical specialists, and mental health provider knowledge of chronic medical conditions. Predicted uptake of a realistic service showed inequalities across income, parental education, and single parent status. A service comprising preferred features was predicted to eliminate these inequalities. Conclusions: Reducing cost and wait time for mental health services could reduce unmet need among children with chronic medical conditions. Specific approaches to tackle the high levels of unmet needs in this group include equipping medical specialists to recommend mental health providers and training mental health providers on the impacts of chronic medical conditions on children. Offering preferred services could increase uptake and reduce inequalities in mental health care. What is known about the topic? Children with chronic medical conditions have high rates of unmet need for mental healthcare. Qualitative research has indicated features of mental health services that may be important to consider in service design to address these unmet needs. What does this paper add? A detailed understanding of parents' preferences for features of mental health services for children with chronic medical conditions, including their importance and prediction of uptake under different scenarios. What are the implications for practitioners? Parents preferred services with recommendation from specialists, mental health providers who understand the impact of chronic conditions, lower cost, and shorter wait time. Offering preferred mental health services is predicted to significantly reduce unmet needs and reduce inequalities in care. [ABSTRACT FROM AUTHOR]

Objective: Many cancer care services (CCS) provide pragmatic models of emergent care for their patients as part of 'business as usual' without understanding the scope of this work. We aimed to describe an Australian CCS-led model of emergent care and quantify and profile emergent care provided over a 6-month period to understand scope and demand. Methods: This prospective cohort study was performed at a large tertiary hospital on the eastern coast of Australia in 2016. The study explored emergent care provided during business hour and after-hours, including telephone advice, unplanned care and unplanned admissions. Data were collected via electronic hospital records and clinical nurses regarding who accessed care, why care was accessed, what care was provided and how the episode of care ended. Results: Between March and September 2016, 1412 episodes of unplanned care were provided in the CCS-led model of care, including 307 episodes of telephone advice (237 patients; min max 1–4 episodes per patient; 825 episodes of unplanned care (484 patients; min max 1–9 episodes per patient) and 280 unplanned admissions (233 patients; min max 1–6 episodes per patient). During the same time, an additional 459 unplanned admissions (361 patients) occurred via the emergency department (ED), of which 125 (27.2%) occurred during business hours which could have been managed by the CCS. Most people who received care experienced issues associated with disease or treatment and had received systemic anticancer therapy in the past 30 days. Conclusions: The data demonstrate that a significant volume of emergent care was provided within the CCS over the study period, in addition to planned cancer treatment. Due to the ever-increasing demands on EDs and the significant need for emergent care for people with cancer, there is need for CCS-led models of care to provide specialist emergent care specifically for people who are receiving systemic anticancer therapy. Such models must be adequately resourced to meet the needs of patients, carers and healthcare professionals. What is known about the topic?: There is increasing focus on innovative models of emergent care for people with cancer in the out-patient setting to relieve pressure on EDs and improve patient experiences. Limited literature has focused on such models in the Australian context. What does this paper add?: This paper describes, quantifies and profiles care provided in a pragmatic CCS-led model of emergent care in a large tertiary hospital in Australia over 6 months. The data demonstrate significant demand for emergent care within business hours, as well as out of hours, predominantly for people undergoing systemic anticancer therapy. What are the implications for practitioners?: The findings of this study highlight the need for CCS to develop pragmatic models of emergent care. Appropriate resources, infrastructure, policies and procedures are required to adequate meet the needs of patients and carers. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has brought into focus obligations for health services to protect the health and safety of their staff, arising from Occupational, Health and Safety legislation and the duty of care owed by a health service as an employer. Health workers, by nature of their work, are a particularly at-risk population in the context of COVID-19. This article examines the legal standard of care that healthcare employers owe their staff in terms of reduction of risk exposure, both physically and psychologically, to COVID-19, the obligation to provide staff with personal protective equipment, adequate hygiene, cleaning and the consequences for breaching these standards. This article also explores the right to dismiss employees who are non-compliant with their obligations. What is known about the topic?: It is well known that health workers are an at-risk population for COVID-19, particularly those with direct exposure to affected patients. Since early 2020, healthcare services have faced substantial challenges in managing employee risk while complying with Occupational, Health and Safety law in Australia. What does this paper add?: This paper explores the standard of care that healthcare services owe their staff in terms of reduction of risk exposure within the current Australian legal framework, as well as the rights and obligations of healthcare service employees. What are the implications for practitioners?: Health services should be aware of the range of legal obligations to protect healthcare workers from the consequences of COVID-19 in order to minimise risk as much as reasonably practicable for employees. This includes ensuring access to adequate personal protective equipment, psychological support, adequate hygiene and cleaning of the physical workspace as well as the appropriate reporting of incidents and exposures. [ABSTRACT FROM AUTHOR]

Objective. This paper provides an update and overview of the law governing direct-to-consumer (DTC) advertising of autologous stem cell interventions (ASCIs) in Australia. It follows significant changes to the advertising regulations made in 2018. Methods. The paper reviews the three primary sources or 'centres' of law regulating ASCIs in Australia, together with the relevant guidance documents that supplement these sources. It provides analysis of how the post-2018 advertising regulations, contained in the Therapeutic Goods Act 1989 (Cwlth), apply to all 'biologicals', including ASCIs. It demonstrates how these three sources of law interact with one another and outlines the new tiered offence regime that applies to contraventions of these prohibitions. Results. The analysis demonstrates that DTC advertising of ASCIs in Australia is strictly controlled, with primary legislation prohibiting the advertising of biologicals altogether. Conclusions. The polycentric legal regime regulating biologicals in Australia clearly makes DTC advertising of ASCIs unlawful. Health practitioners who promote ASCIs, either online, in print or in other media forms, may be penalised in different ways and by different authorities. [ABSTRACT FROM AUTHOR]

Objective: Substitute decision makers (SDMs) can be required to make difficult health care decisions on behalf of individuals lacking decision-making capacity. Online resources may be helpful in preparing and supporting SDMs. This study systematically explored the frequency, content and usability of Australian online resources containing health care substitute decision-making content written for consumers. Methods: In April 2019, Google searches were conducted to identify online resources containing health care substitute decision-making content for consumers. Analysis comprised mapping resource characteristics, including target audience (individual-specific, SDM-specific, mixed) and thematic analysis of content. Usability was assessed using the Patient Education Materials Assessment Tool (PEMAT). Results: Of the 61 resources identified, the most frequent were webpages (57%), individual-specific (43%) and those produced by government organisations (31%). Only 15 resources (24%) were written for SDMs. Content themes identified were: defining the scope of the SDM role (93%); recommended traits or characteristics of SDMs (80%); instructions or principles regarding standards for decision making (75%); duties of SDMs (70%); and supports (46%), rights (16%), barriers (8%) and benefits (5%) for SDMs. The median (interquartile range) PEMAT scores (out of 100) were 66 (27) for understandability and 60 (55) for actionability. Conclusions: SDMs have a vital role in making decisions for people lacking decision-making capacity. Online resources are a potential source of information and support for SDMs in Australia. This study identified key gaps in availability, content and usability of existing SDM resources, highlighting the need for the further development of such resources. We suggest that future resource development include SDMs in the design and evaluation processes. What is known about the topic?: An aging population and a greater need for decisions to be made on behalf of others who lack capacity means that health care substitute decision-making is occurring more frequently. Appointing one or more SDMs may occur as part of the advance care planning process. However, being a healthcare SDM can be difficult and stressful. People frequently use the Internet to search for health-related information. What does this paper add?: This paper systematically examined the frequency, content and usability of existing Australian online resources with substitute decision-making content written for a consumer audience in English, and identified key gaps in online resources available to support SDMs. What are the implications for practitioners?: Although there is a need for resources written for SDMs, authors of online resources need to pay careful attention to the purpose, content and usability of their resource. Future resource development should include input from SDMs and involve them in evaluation to assess whether the resources meet target audience needs. [ABSTRACT FROM AUTHOR]

Background: Chronic pain is a major and growing public health issue. Multidisciplinary tertiary pain services cannot meet patient demand and greater involvement of primary care is needed. The aims of this study were to understand the needs and priorities of Australian primary health networks (PHNs) related to the management and secondary prevention of chronic pain; map current PHN chronic pain initiatives and identify gaps; highlight key enablers to implementation; and highlight solutions identified by PHNs to increase capacity to commission initiatives. Methods: Mixed methods were used, including: a review of PHN needs assessments; and consultation with PHN executive-level staff and program managers from 27 out of the 28 PHNs, and the WA Primary Health Alliance (WAPHA – a state alliance between three Western Australian PHNs) via telephone interviews, online surveys, a workshop, a deliberative dialogue and email consultation. Results: Chronic pain was identified as a health and/or service need by approximately half of PHNs. Barriers for PHNs to identifying chronic pain as a need or priority are highlighted. Gaps identified by the mapping included: initiatives related to the secondary prevention of chronic pain (post-surgery or post-injury), digitally enabled consumer and health professional chronic pain initiatives, and chronic pain initiatives for specific populations groups such as Aboriginal and Torres Strait Islander people. Among existing PHN practice, two exemplar evidence-based initiatives suitable for scale-up across PHNs in Australia were identified: multidisciplinary community-based pain programs, and an online health professional capacity-building initiative, Project ECHO (chronic pain). Solutions identified by PHNs to increase capacity to commission initiatives included: co-funding initiatives across different PHN funding streams, collaborative initiatives between PHNs, and co-commissioning with government and non-government partners. Conclusions: Chronic pain has been classified as a disease in itself through the World Health Organization. PHNs recognising chronic pain as a distinct condition in PHN needs analysis and data collection would lead to more dedicated funding. PHNs could do more to improve the secondary prevention and management of chronic pain. A self-identified need for greater collaboration across PHNs and co-commissioning with local and state governments and non-government partners would help to build PHN capacity. Few studies focus on Australian Primary Health Networks (PHNs) and little is known about the needs, priorities and scope of work of PHNs related to the management and secondary prevention of chronic pain. This paper describes the needs and priorities of PHNs; maps current PHN chronic pain initiatives and identifies gaps; and highlights key enablers to implementation. It also highlights solutions identified by PHNs to increase capacity to commission initiatives. [ABSTRACT FROM AUTHOR]

Objective: To describe the change in telemental health service volume that resulted from the introduction of the Medicare Benefits Schedule (MBS) item numbers in 2020 for services provided by psychologists and psychiatrists in Australia for a 3-year period, from January 2019 to December 2021. Methods: Quarterly MBS activity and cost data for mental health services provided by consultant psychiatrists, clinical psychologists, and psychologists between January 2019 and December 2021 were extracted from the MBS statistics website. Data were grouped by profession and delivery mode (in-person, telephone or videoconference) and reported using activity counts. Descriptive analysis and interrupted time-series regression analysis were conducted. Specific descriptive explorations were also conducted for psychiatrists, including: new client consultations, review or general consultations, and group consultations. Results: The delivery of mental health services by telehealth (telemental health) during the pandemic has increased (P < 0.0001). When the pandemic started in March 2020, telemental health services provided by psychiatrists and psychologists increased from a combined 1–2% per quarter to 29% videoconference and 20% telephone in quarter two 2020. After the onset of the pandemic, videoconference remained the primary form of telehealth for these professions. However, the telephone accounted for approximately a third of the telehealth activity after the new item numbers were introduced. Conclusion: Telemental health services are more likely to be conducted by videoconference than by telephone. The observed increase in telehealth service activity confirms how crucial appropriate funding models are to the sustainability of telehealth services in Australia. The growth in telehealth was used to support people with mental health conditions in Australia. What is known about the topic? Psychologists and psychiatrists were among the earliest adopters and were assigned some of the first telehealth item numbers on the Medicare Benefits Schedule. What does this paper add? The delivery of mental health services by telehealth during the pandemic has increased. Telemental health services are more likely to be done by videoconference in psychiatry and psychology than by other professions. What are the implications for practitioners? The observed increase in telehealth service activity confirms how crucial appropriate funding models are to the sustainability of telehealth services in Australia. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify potential model of care approaches and systems processes for people presenting to acute healthcare settings with mental health problems, including mental illnesses. Methods: Five (consensus) nominal group technique sessions were conducted in 2019 with a purposive sample of stakeholders from health, police, ambulance and consumer agencies (n = 21). Sessions were recorded, transcribed and analysed for thematic content. Results: Potential model of care approaches and systems processes for people with mental health problems in the emergency department include: a skilled collaborative approach to care; consumer-focused service; knowledge improvement; early assessment; the development of models, systems and processes; and the built environment. In the broader acute care setting, the themes of formal care, linking of services, enhancing informal and innovative care options, improving information sharing and enhancing training and education were identified. Conclusions: Coherent and multifaceted approaches to the provision of care to people with mental health problems and diagnosed mental illnesses who are requiring emergency care include the linking and sharing of systems and information, changing the built environment and exploring new models of service delivery. What is known about the topic?: There is considerable evidence of interventions used in the emergency department and acute healthcare settings for this vulnerable group of people with mental health problems and diagnosed mental illnesses; however, the evidence for appropriate model of care approaches and systems processes is limited. What does this paper add?: For people with mental health problems in emergency departments and for people with diagnosed mental illnesses in acute care settings, targeted directions to further support treatment include the linking and sharing of systems and information, changing the built environment and exploring new models of service delivery. What are the implications for practitioners?: Planning changes to services for mental health clients with acute problems needs to incorporate clinicians, health service planners, architects and a range of emergency services personnel. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has challenged the mental health of communities worldwide, with the triple pressures of financial insecurity, lockdowns, and worry about the infection. Australia rapidly deployed resources to protect the mental wellbeing of the community through supplementing existing services, supporting at-risk groups, investing in social supports, embracing technology, and supporting the health workforce. This paper describes the Australian Government's investment in mental health during the COVID-19 pandemic in relation to the 10 priority areas identified in Australia's National Mental Health Pandemic Response Plan. The COVID-19 pandemic and associated public health measuresgenerated substantial and ongoing challenges for the mental health and wellbeing of Australian communities. Australian Government funded initiatives were rapidly instituted between different levels of government and with community mental health organisations. These policy actions aimed to provide agile responses to promote community resilience and strengthen services for vulnerable groups, including older people, those with existing mental health conditions, Aboriginal and Torres Strait Islander peoples, and health and essential service providers. [ABSTRACT FROM AUTHOR]

Objective: Despite needs, people with advanced non-malignant respiratory disease are infrequently referred to palliative care services. Integrated models of palliative care and respiratory service delivery have been advocated to address this inequity of access. This study mapped current ambulatory palliative care service provision for patients with advanced non-malignant respiratory disease in Australia and New Zealand. Methods: An online survey was distributed to the palliative care physician membership of the Australian and New Zealand Society of Palliative Medicine. Information was sought regarding access to specific breathlessness and integrated respiratory and palliative care services, and their operation. Data were described using descriptive statistics. Results: In all, 133 respondents (93 from Australia, 40 from New Zealand; representing 55 Australian and 26 New Zealand discrete sites) with complete data were available for analysis. More than half the respondents reported seeing patients with advanced non-malignant respiratory disease frequently (56/97; 58%), and 18 of 81 services (22%) reported having breathlessness or integrated respiratory and palliative care services caring for this patient group. Such services were mostly staffed by respiratory and palliative care doctors and nurses and based in the clinic environment, with limited support available outside this setting. Of the 63 respondents without existing breathlessness or integrated services, 49 (78%) expressed interest in their establishment, with limited resources cited as the most common barrier. Conclusions: There is limited availability of integrated respiratory and palliative care or specialised breathlessness services in Australia and New Zealand despite widespread support by palliative care physicians. This study provides a snapshot to inform strategic service development. What is known about the topic?: People with advanced respiratory disease have very significant morbidity with complex needs equivalent to, and in many cases more intense than, people with end-stage lung cancer; they also have significant mortality. Yet, these people frequently do not access palliative care services. The establishment of integrated respiratory and palliative care services has been advocated as an effective means to overcome the barriers to palliative care access. Such services have demonstrated improved patient and family-reported outcomes, as well as service-level improvements. What does this paper add?: This paper maps the availability of integrated respiratory palliative care services in Australia and New Zealand. We reveal that although most palliative care physicians report seeing patients with advanced respiratory disease in practice, just one-fifth of services report having an integrated service approach. There was high interest and enthusiasm for such services (78%), but resources limited their establishment. What are the implications for practitioners?: Palliative care services recognise the needs of patients with advanced respiratory disease and the benefits of integrated respiratory and palliative care services to address these needs, but scarcity of resources limits the ability to respond accordingly. This study provides a snapshot of current service level to inform strategic development. [ABSTRACT FROM AUTHOR]

Objective: Healthcare delivery models describe the organisation of healthcare practitioners and other resources to provide health care for a defined patient population. The organisation of health care has a predominant effect on the receipt of timely and appropriate health care. Efforts to improve healthcare delivery should be evidence informed, and large numbers of evaluations of healthcare delivery models have been undertaken. This paper presents a scoping review of Australian evaluations of new healthcare delivery models to inform a discussion of the appropriate use of such evidence to improve the efficiency and sustainability of the Australian health system. Methods: A systematic scoping review was undertaken, following an a priori published protocol. PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for primary comparative studies of healthcare delivery models undertaken in Australia and published between 2009 and 2018. Primary prevention studies, such as health promotion activities, were excluded. Results: Of 14 923 citations, 636 studies were included in the scoping review. Of these, 383 (60%) were randomised control trials. There were 18 clinical specialties in which over 10 evaluations were identified. Most models involved allied health practitioners or nurses. Conclusion: Evaluations of healthcare delivery models provide important evidence that can be used to improve the use of the most important and costly assets of health systems, namely the healthcare practitioners who deliver health care. A nationally coordinated system is required to support local health services to assess the local value of alternative healthcare delivery models. What is known about the topic?: The organisation and delivery of health care is continuously evolving in response to changes in the demand and supply of health care. New healthcare delivery models are often evaluated in specific locations, but it is not clear how such evidence informs the delivery of care in other locations. What does this paper add?: This paper reports the findings of a scoping review of Australian evaluations of healthcare delivery models, highlighting the large and increasing number of such evaluations that have been published in the past 10 years. What are the implications for practitioners?: Opportunities to improve health system efficiency are likely being lost due to the underuse of the available Australian evidence on new healthcare delivery models. Local health services need support to interpret such evidence in their local context, which could be provided through the development of a national framework for local evaluation. [ABSTRACT FROM AUTHOR]

Objective: The aims of this study were to estimate the average annual out-of-pocket (OOP) expenditure on health care by households in Australia in 2015–16, and to compare this with the estimate for 2009–10. Methods: Data from the most recent Household Expenditure Survey (HES) conducted by the Australian Bureau of Statistics were used. Various statistical methods were used to estimate the annual OOP expenditures at the household and national levels. Results: The average annual OOP expenditure was A$4290 per household, representing 5.8% of the amount spent on all goods and services. Private health insurance (PHI) premiums, although not a direct expenditure on health care, were 40.6% of the total OOP expenses. Of the remaining 59.4%, nearly half was spent on doctors and other health professionals, and approximately one-third was spent on medicines. Dental treatments and specialist consultations were the most expensive, whereas visits to general practitioners incurred the least OOP expenditure. Households with PHI (58.6%) spent fourfold more on health care than those not insured. Compared with the 2009–10 survey, the biggest increases were in the cost of PHI (50.7%) and copayments to specialists (34.8%) and other health professionals (42.0%). Conclusions: OOP expenditure on health care as a proportion of the total household expenditure on all goods and services has increased by more than 25% between 2009–10 and 2015–16. What is known about the topic?: Australian households incur OOP expenses for health care in Australia for a wide range of goods and services, such as copayments to doctors and other health professionals beyond the Medicare rebates, the cost of medicines and other pharmaceutical goods not covered entirely by the Pharmaceutical Benefits Scheme and PHI premiums. Although other estimates of OOP expenditure are available in official reports of the Australian Institute of Health and Welfare, they are based on administrative records rather than consumer reports, and cannot be disaggregated by item or the characteristics of households. What does this paper add?: This paper provides detailed information on OOP expenditure on health care as reported by a probability sample of households interviewed for the HES conducted by the ABS during 2015–16. These estimates of OOP expenditure, based on consumer reports, add a further dimension to the information available from administrative records only. What are the implications for practitioners?: Practitioners should take account of the effect of increasing copayments for their services, especially on patients belonging to the lower socioeconomic categories. Increasing copayments may lead to people foregoing medical care. Health planners and politicians should note the steady upward drift in OOP expenses and factor these into their policies for future funding of health care. [ABSTRACT FROM AUTHOR]

Climate change adaptation can be defined as a form of risk management (i.e. assessing climate change-related risks and responding appropriately so that the risks can be pre-emptively minimised and managed as they arise). Adapting to climate change by hospital and community health services will entail responding to changing health needs of the local population, and to the likely effects of climate change on health service resources, workforce and infrastructure. In this paper we apply a model that health services can use to predict and respond to climate change risks and illustrate this with reference to Sydney's Local Health Districts (LHDs). We outline the climate change predictions for the Sydney metropolitan area, discuss the resulting vulnerabilities for LHDs and consider the potential of LHDs to respond. Three 'core business' categories are examined: (1) ambulance, emergency and acute health care; (2) routine health care; and (3) population and preventative health services. We consider the key climate change risks and vulnerabilities of the LHDs' workforce, facilities and finances, and some important transboundary issues. Many Australian health services have existing robust disaster plans and management networks. These could be expanded to incorporate local climate and health adaptation plans. What is known about the topic?: There is an inextricable relationship between climate change and human health, with important implications for the delivery of health services. Climate change will affect health service demand, and the resources, workforce and infrastructure of health services. What does this paper add?: This paper outlines how local health services can use existing data sources and models for assessing their climate change-related risks and vulnerabilities to predict, prepare for and respond to those risks. This is illustrated with reference to Sydney's LHDs. What are the implications for practitioners?: Adaptation to climate change by health services is an important component of risk management. Local health services need to prepare for the effects of climate change by assessing the risks and developing and implementing climate and health adaptation plans. [ABSTRACT FROM AUTHOR]

Objective. Chronic pain and cardiovascular disease (CVD) have a high disease burden. This research aimed to understand whether Australian primary health networks (PHNs) are recognising the need for the prevention of these conditions by investigating what local health and service issues have been identified. Methods. Separate sets of needs assessments were analysed for chronic pain and CVD for all 31 PHNs using a document analysis approach. Framework analysis was undertaken to ascertain the types of health and service issues, prevention-related issues and supporting data sources identified, as well as to quantify the number of PHNs identifying these issues. Results. Fewer PHNs identified health issues for chronic pain (n = 13) compared with CVD (n = 30), with the most common being disease prevalence and burden supported by National Health Survey data. Service issues were identified by fewer than half the PHNs (n = 13 for each disease), which were largely informed by stakeholder consultation and related to service integration, service accessibility and health professional training. Prevention-related issues were frequently identified for CVD (n = 26), but not chronic pain (n = 3). Conclusions. This paper highlights the need for a greater focus on chronic pain- and CVD-related issues by PHNs. This could be supported nationally by recognising chronic pain and risk factors in national datasets and PHN performance frameworks, and locally via greater stakeholder consultation to inform PHN population health planning. [ABSTRACT FROM AUTHOR]

Objective: There is an impetus for the timely diagnosis of dementia to enable optimal management of patients, carers and government resources. This is of growing importance in the setting of a rising prevalence of dementia in an aging population. The Australian Clinical Practice Guidelines and Principles of Care for People with Dementia advocate referral to comprehensive memory services for dementia diagnosis, but in practice many patients may be diagnosed in other settings. The aim of the present study was to obtain evidence of the roles, effectiveness, limitations and accessibility of current settings and services available for dementia diagnosis in Australia. Methods: A literature review was performed by searching Ovid MEDLINE using the terms 'dementia' AND 'diagnosis OR detection'. In addition, articles from pertinent sources, such as Australian government reports and relevant websites (e.g. Dementia Australia) were included in the review. Results: Literature was found for dementia diagnosis across general practice, hospitals, memory clinics, specialists, community, care institutions and new models. General practitioners are patients' preferred health professionals when dealing with dementia, but gaps in symptom recognition and initiation of cognitive testing lead to underdiagnosis. Hospitals are opportunistic places for dementia screening, but time constraints and acute medical issues hinder efficient dementia diagnosis. Memory clinics offer access to multidisciplinary skills, demonstrate earlier dementia diagnosis and potential cost-effectiveness, but are disadvantaged by organisational complexities. Specialists have increased confidence in diagnosing dementia than generalists, but drawbacks include long wait lists. Aged care assessment teams (ACAT) are a potential service for dementia diagnosis in the community. A multidisciplinary model for dementia diagnosis in care institutions is potentially beneficial, but is time and cost intensive. New models with technology allow dementia diagnosis in rural regions. Conclusion: Memory clinics are most effective for formal dementia diagnosis, but healthcare professionals in other settings play vital roles in recognising patients with dementia and initiating investigations and referrals to appropriate services. What is known about this topic?: Delays in dementia diagnosis are common, and it is unclear where majority of patients receive a diagnosis of dementia in Australia. While the Australian Clinical Practice Guidelines and Principles of Care for People with Dementia advocate referrals to services such as memory clinics for comprehensive assessment and diagnosis of dementia, such services may have limited capacity and may not be readily accessible to all. What does this paper add?: This paper presents an overview of the various settings and services available for dementia diagnosis in Australia including evidence of the roles, accessibility, effectiveness and limitations of each setting. What are the implications for practitioners?: This concerns a disease that is highly prevalent and escalating, and highlights the roles for practitioners in various settings including general practices, acute hospitals, specialist clinics, community and nursing homes. In particular, it discusses the potential roles, advantages and challenges of dementia diagnosis in each setting. [ABSTRACT FROM AUTHOR]

Objective: The climate crisis necessitates urgent decarbonisation. The health sector must address its large carbon footprint. In the present study, we sought healthcare thought leaders' views about a future environmentally sustainable health system. Methods: The present study was a qualitative exploratory study consisting of semistructured, in-depth interviews with 15 healthcare thought leaders from Australia, the UK, the US and New Zealand. Audio recordings of the interviews were transcribed and analysed by matrix display and thematic analysis. Results: Overall, healthcare thought leaders believe that to reduce the carbon footprint of healthcare we need to look beyond traditional 'green' initiatives towards a more fundamental and longer-term redesign. Five main themes and one 'key enabler' (information communication technology) were identified. In this paper we draw on other relevant findings, but chiefly focus on the fifth theme about reshaping the role of healthcare within society and using the size and influence of the health sector to leverage wider health, environmental and societal benefits. Conclusions: These ideas represent potentially low-carbon models of care. The next step would be to pilot and measure the outcomes (health, environmental, financial) of these models. What is known about the topic?: The health sector needs to reduce its large carbon footprint. Traditional 'green' initiatives, such as recycling and improving energy efficiency, are insufficient to achieve the scale of decarbonisation required. What does this paper add?: Healthcare thought leaders surveyed in the present study suggested that we also consider other, non-traditional ways to achieve environmental sustainability. In this paper we discuss their ideas about adopting an anticipatory approach to healthcare using predictive analytics, and using the size and influence of the health sector to effect wider health and environmental benefits. What are the implications for practitioners?: Achieving an environmentally sustainable healthcare system is likely to require broad and fundamental (i.e. transformational) change to the current service model. Health practitioners throughout the sector must be closely engaged in this process. [ABSTRACT FROM AUTHOR]

Objective: In response to escalating alcohol and other drug (AOD)-related emergency department (ED) presentations, a tertiary Melbourne hospital embedded experienced AOD clinical nurse consultants in the ED on weekends to trial a model for screening, assessment and brief intervention (BI). The aim of the present study was to evaluate the relative contributions of AOD to ED presentations and to pilot a BI model. Methods: Using a customised AOD screening tool and a framework for proactive case finding, screened participants were offered a comprehensive AOD assessment and BI in the ED. Immediate effects of the intervention were evaluated via the engagement of eligible individuals and a self-administered 'intention to change' survey. Results: Over the 32-month pilot, 1100 patients completed a comprehensive AOD assessment, and 95% of these patients received a BI. The most commonly misused substances were, in order, alcohol, tobacco, amphetamine-type stimulants, gamma-hydroxybutyrate and cannabis. Thirty-two per cent of patients were found to be at risk of dependence from alcohol and 25% were found to be at risk of dependence from other substances. Forty per cent of the people assessed reported no previous AOD support or intervention. On leaving the ED, 78% of participants reported an intention to contact community support services and 65% stated they would change the way they used AOD in the future. Conclusion: This study of a pilot program quantifies the relative contribution of AOD to ED presentations and demonstrates that hospital EDs can implement a feasible, proactive BI model with high participation rates for people presenting with AOD-related health consequences. What is known about the topic?: Clinician-led BI for high-risk consumption of alcohol has been demonstrated to be effective in primary care and ED settings. However, hospital EDs are increasingly receiving people with high-risk AOD-related harms. The relative contribution of other drugs in relation to ED presentations has not been widely documented. In addition, the optimal model and effects of AOD screening and BI programs in the Australian ED setting are unknown. What does this paper add?: This paper describes a 'real-life' pilot project embedding AOD-specific staff in a metropolitan Melbourne ED at peak times to screen and provide BI to patients presenting with AOD-related risk and/or harms. The study quantifies the relative contribution of other drugs in addition to alcohol to ED presentations and reports on this model's much higher levels of patient engagement in receiving BI than has been reported previously. What are the implications for practitioners?: This study demonstrates the relative contribution of drugs, in addition to alcohol, to ED presentations at peak weekend times. Although BI has been well proven, the pilot project evaluated herein has demonstrated that by embedding AOD-specific staff in the ED, much higher rates of patient engagement, screening and BI can be achieved. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to investigate whether the content of annual Victorian quality of care reports had an increased consumer participation focus following the introduction of the National Safety and Quality Health Service (NSQHS) Partnering with Consumers standard. Methods: A mixed-methods approach comprising a comparative descriptive observational study design with quantitative data analysis was used. Nine large Victorian metropolitan public health services' annual quality of care reports from 2011 and 2014 were analysed using a newly devised analysis framework consisting of elements of the NSQHS 'Partnering with Consumers' standard and minimal requirements for Quality of Care reporting by the Department of Health and Human Services. Results: Of the nine 2014 quality of care reports, in only three were total scores higher compared with scores in the 2011 reports; in one of the 2014 reports, the total scores remained the same, and in the remaining five reports total scores were lower than in the 2011 reports. Overall, there was an improved total score for the 2014 reports compared with the 2011 reports, corresponding to a higher consumer participation focus. Conclusion: Overall, the present study demonstrated mixed findings and, in some cases, lower scores for the 2014 reports, which was after the introduction of the Partnering with Consumers NSQHS standard, compared with the 2011 reports. Overall, there is future scope to enhance the degree of consumer participation evident within the quality of care reports. What is known about the topic?: Partnering with consumers has been associated with improved clinical outcomes, decreased readmission rates and rates of hospital-acquired infections, and improved adherence to treatment recommendations and health literacy. Engaging consumers has been recognised as a means to increase the accessibility and appropriateness of healthcare to individuals. Public reporting is a tool through which health services communicate with and engage their consumers in order to improve the quality of care they provide, and is a key element in Australia of the NSQHS Partnering with Consumers standard. What does the paper add?: This paper links the principles of consumer participation with public reporting. The paper highlights the potential for healthcare organisations to use their public reporting media to engage with consumers and communicate about the quality of care they deliver. What are the implications for practitioners?: The unexpected findings of a lower emphasis on consumer participation suggests the need for Victorian health services to review the purpose and processes for developing the publicly reported quality of care reports in order to improve their compliance. [ABSTRACT FROM AUTHOR]

There has been a growth in Australian school-based nurses to address the inequities confronted by vulnerable students and school populations. Failure to address inequities can be evidenced in intergenerational poverty, poorer health and educational attainment and diminished life opportunities. School-based nurses are ideally located to advocate for public health policies and programs that address social determinants that detrimentally affect the health of school populations. However, school-based nurses can confront professional and speciality challenges in extending their efforts beyond individual student advocacy to effect change at the school population level. Guidance is required to redress this situation. This paper describes public health advocacy, the professional and speciality advocacy roles of school-based nurses and the barriers they confront in advocating for the health of school populations and strategies that can be used by key stakeholders to enhance school-based nursing public health advocacy efforts. School-based nurses who are competent, enabled and supported public health advocates are required if we are to achieve substantial and sustained health equity and social justice outcomes for vulnerable school populations. School-based nurses are ideally located to advocate for services and policies to address the health inequities experienced by vulnerable school populations. However, these nurses can confront barriers that limit their capacity to embed health advocacy into their practice and to meaningfully effect change. Guidance is required to redress this situation. School-based nurses who are competent and supported health advocates are required to achieve substantial and sustained health equity and social justice outcomes for vulnerable students and school populations. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine, in the first 2 years after the last planned appointment with paediatric diabetes services for young people with Type 1 diabetes (T1D): (1) the number of planned and unplanned healthcare contacts and HbA1c measurements made; (2) factors linked to diabetes-related service use; and (3) factors predictive of the number of planned and unplanned service contacts, and of meeting the minimum number of planned service contacts. Methods: Healthcare records of a major public healthcare provider in Australia were audited for preventive and acute service use by young people with T1D transferring from paediatric to adult public healthcare services. Statistical analyses included use of t-tests and logistic regression modelling. Results: Of 172 young people with T1D, 21% had no planned specialist care and 49% accessed acute services for diabetes-related matters. Residents of metropolitan areas and users of continuous subcutaneous insulin infusion therapy were more likely to access specialist care and were less likely to use acute services for unplanned care. Those achieving a minimum of nine planned care contacts in 2 years had a shorter duration between the last paediatric and first adult healthcare contact. Conclusions: Lack of specialist care in early adult years and non-metropolitan relative disadvantage compromise the present and future health of young people with diabetes. What is known about the topic?: Well-managed transition is thought to offer the best chance of achieving cost-effective continuing engagement with specialist services for planned preventive care, effective T1D self-management and deferral or early attention to diabetes-related vascular complications. However, transition is commonly reported as problematic. What does this paper add?: The findings of this study indicate a positive trend but continuing need to improve transition care for young people with T1D, especially those living in non-metropolitan areas and those not using continuous subcutaneous insulin infusion therapy. What are the implications for practitioners?: Without service innovation, suboptimal and delayed access to planned care, high use of acute services for unplanned care and poor glycaemic control will continue to threaten the future health and well-being of young people with T1D. [ABSTRACT FROM AUTHOR]

With the aging population, the tide of chronic disease is rising with attendant increases in health service need. Integrated care and patient-centred approaches, which established partnerships between a regional Hospital and health service (HHS), the local primary health network and local general practitioners (GPs), were identified as exemplars of an approach needed to support growing community health needs. This paper summarises the findings from a process evaluation of four GP–specialist care integration programs with the aim of identifying recommendations for embedding integrated GP–specialist care into routine practice within the HHS. The process evaluation of the integration programs drew on input from a multidisciplinary expert advisory group and data collected through face-to-face semi-structured interviews with key stakeholders, as well as surveys of participating GPs and patients. Overarching findings were identified and grouped under six themes: interdisciplinary teamwork; communication and information exchange; the use of shared care guidelines or pathways; training and education; access and accessibility; and funding. Within each theme, key challenges and enablers emerged. The findings of this study highlight benefits and challenges associated with the establishment of integrated care between primary and secondary care providers, leading to the development of key recommendations for routine integration. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to explore the features of sustainable antimicrobial stewardship (AMS) programs in Australian rural hospitals and develop recommendations on incorporating these features into rural hospitals' AMS programs. Methods: Lead AMS clinicians with knowledge of at least one AMS program sustained for >2 years in a health service in rural Australia were recruited to the study. A series of interviews was conducted and the transcripts analysed thematically using a framework method. Results: Fifteen participants from various professional disciplines were interviewed. Key features that positively affected the sustainability of AMS programs in rural hospitals included a hospital executive who provided strong governance and accountability, dedicated resources, passionate local champions, area-wide arrangements and adaptability to engage in new partnerships. Challenges to building AMS programs with these features were identified, particularly in engaging hospital executive to allocate AMS resources, managing the burn out of passionate champions and formalising network arrangements. Conclusions: Strategies to increase the sustainability of AMS programs in rural hospitals include using accreditation as a mechanism to drive direct resource allocation, explicit staffing recommendations for rural hospitals, greater support to develop formal network arrangements and a framework for integrated AMS programs across primary, aged and acute care. What is known about the topic?: AMS programs facilitate the responsible use of antimicrobials. Implementation challenges have been identified for rural hospitals, but the sustainability of AMS programs has not been explored. What does this paper add?: Factors that positively affected the sustainability of AMS programs in rural hospitals were a hospital executive that provided strong governance and accountability, dedicated resources, network or area-wide arrangements and adaptability. Challenges to building AMS programs with these features were identified. What are the implications for practitioners?: Recommended actions to boost the sustainability of AMS programs in rural hospitals are required. These include using accreditation as a mechanism to drive direct resource allocation, explicit staffing recommendations for rural hospitals, greater support to develop network arrangements and support to create integrated AMS programs across acute, aged and primary care. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to describe patterns of health service utilisation among the Australian population with cancer compared with the general population. Methods: Data for all respondents aged ≥25 years from two successive National Health Surveys conducted between 2011 and 2014 were analysed. Respondents with a history of cancer were identified as the cancer group, whereas all other respondents who did not report having had a cancer were included in the non-cancer control group. Comparisons were made between the two groups using logistic regression models. Results: The population with cancer was more likely to report having consulted their general practitioner, specialist, chemist, dietician, naturopath, nurse, optometrist, dentist, audiologist and other health professionals than the non-cancer population. The cancer population was also more likely to be admitted to hospital and to have visited an out-patient clinic, emergency department and day clinic. The presence of comorbidity and a current cancer were associated with a greater likelihood of receiving health services among the population with cancer. Conclusion: The population with cancer used health services significantly more than the non-cancer population. Further studies are urgently needed to identify optimal approaches to delivery of care for this population, including barriers and enablers for their implementation. What is known about the topic?: Multimorbidity is highly prevalent among the cancer population due to risk factors shared between cancer and other chronic diseases, and the development of new conditions resulting from cancer treatment and cancer complications. However, the Australian healthcare system is not set up optimally to address issues related to multimorbidity. What does this paper add?: This study is the first step in quantifying health services use by the population with cancer compared with the general population without cancer. Cancer survivors have an increased need for specific health services, particularly among those with multimorbidity. What are the implications for practitioners?: The development of integrated care models to manage multiple chronic diseases aligned with the Australian National Strategic Framework for Chronic Conditions is warranted. Further studies are urgently needed to identify optimal approaches to delivery of care for this population, including barriers and enablers for their implementation. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess 15-year trends in unplanned readmissions in an Australian regional health service. Methods: Drawing on data held in the Illawarra Health Information Platform (IHIP), this longitudinal retrospective study of adults admitted to hospital between 2001–02 and 2015–16 assessed rates of unplanned all-cause readmissions within 30 days ('early') and 1–6 months ('late') following discharge. Rates were compared over time and between patient groups. Results: Age-adjusted early readmission rates declined over the 15 years by an average of 1.3% per annum, whereas late readmission rates increased by an average of 0.6% per annum. Together, there was an overall decline in readmission rates. The entire decline in early readmission rates and a reversal of the increasing trend in late readmission rates occurred since 2010–11. Similar trends occurred across age groups, but were most pronounced among those aged ≥75 years. Conclusions: The decline in readmissions since 2010–11 suggests that the region has achieved improvements in discharge planning and in continuity between hospitals and community-based care. These improvements have occurred across broad patient groups. The longitudinal and linked data held in the IHIP provides a unique opportunity to examine patterns of service utilisation at a regional level. What is known about the topic?: Published reports of longitudinal trends in readmissions are typically limited by short study periods and narrow criteria used to define study populations and readmissions. Australian longitudinal data suggest rates of early readmission have remained relatively unchanged in recent years, despite the focus on readmission rates as a metric to assess the quality and continuity of care. What does this paper add?: This unique longitudinal study reports on long-term readmission trends over 15 years to hospitals within a single geographic area, with trends reported for both early (30-day) and late (1- to 6-month) readmissions by age group and major diagnostic categories. The findings reflect more complex patterns than are typically reported in cross-sectional and more limited longitudinal studies. What are the implications for practitioners?: The results suggest improvements at a regional level that may be associated with care during the initial hospitalisation and discharge (reflected particularly in early readmissions) and in the community (reflected particularly in late readmissions). Future investigations will explore specific patient groups and the effects of specific initiatives, services and models of care to better predict those at risk of readmission and to inform translation locally and further afield. The relationship between readmissions and the use of ambulatory services (primary care, emergency department and out-patient) also warrants further investigation. [ABSTRACT FROM AUTHOR]

Objectives: The aims of this study were to: (1) examine institutional racism's role in creating health outcome discrepancies for Aboriginal and Torres Strait Islander peoples; and (2) assess the management of institutional racism in an Australian hospital and health service (HHS). Methods: A literature review informed consideration of institutional racism and the health outcome disparities it produces. Publicly available information, provided by an Australian HHS, was used to assess change in an Australian HHS in five key areas of institutional racism: inclusion in governance, policy implementation, service delivery, employment and financial accountability. These findings were compared with a 2014 case study. Results: The literature concurs that outcome disparity is a defining characteristic of institutional racism, but there is contention about processes. Transformative change was detected in the areas of governance, service delivery and employment at an Australian HHS, but there was no change in financial accountability or policy implementation. Conclusions: The health outcomes of some racial groups can be damaged by institutional racism. An external assessment tool can help hospitals and health services to change. What is known about the topic?: Institutional racism theory is still developing. An external assessment tool to measure, monitor and report on institutional racism has been developed in Australia. What does this paper add?: This study on institutional racism has useful propositions for healthcare organisations experiencing disparities in outcomes between racial groups. What are the implications for practitioners?: The deleterious effects of institutional racism occur regardless of practitioner capability. The role for practitioners in ameliorating institutional racism is to recognise the key indicator of poorer health outcomes, and to then seek change within their hospital or healthcare organisation. [ABSTRACT FROM AUTHOR]

Efforts to address Indigenous health disadvantage require a refocus on urban settings, where a rapidly increasing majority (79%) of Indigenous Australians live. Proximity to mainstream primary care has not translated into health equity, with the majority of the Indigenous burden of disease (73%) remaining in urban areas and urban Indigenous people continuing to face significant barriers in accessing comprehensive and culturally appropriate care. This paper presents a case study of how the Institute for Urban Indigenous Health (IUIH) has strategically responded to these challenges in South East Queensland – home to Australia's largest and equal fastest growing Indigenous population. The IUIH has developed a new regional and systematised model – a regional health 'ecosystem' – for how primary care is delivered and intersects with the broader health system. Through intentional action, which strengthens the self-efficacy of community, the IUIH System of Care has delivered real gains for the Indigenous population of the region and has the capacity to deliver similar improvements in health access and outcomes in other regions. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to develop a validated model to predict current and future Australian costs for people with dementia to help guide decision makers allocate scarce resources in the presence of capacity constraints. Methods: A hybrid discrete event simulation was developed to predict costs borne in Australia for people with dementia from 2015 to 2050. The costs captured included community-based care, permanent and respite residential aged care, hospitalisation, transitional care, pharmaceuticals, aged care assessments, out of hospital medical services and other programs. Results: The costs borne for people with dementia in Australia are predicted to increase from A$11.8 billion in 2015 to A$33.6 billion in 2050 at 2013–14 prices, ceteris paribus. If real per capita health and social expenditure increased by 1.0% annually, these costs are predicted to increase by around A$14.2 billion to a total of around A$47.8 billion by 2050. Conclusions: This simulation provides useful estimates of the potential future costs that will be borne for people with dementia and allows the exploration of the effects of capacity constraints on these costs. The model demonstrates that the level of real annual per capita growth in health and social expenditure has significant implications for the future sustainability of dementia care in Australia. What is known about the topic?: With the aging of the Australian population, the number of people living with dementia is predicted to rise markedly in the next four decades. As the number of people living with dementia increases, so too will the financial burden these debilitating and degenerative diseases place on private and public resources. These increases are likely to challenge the efficiency and sustainability of many health systems in the developed world. What does this paper add?: This research provides a validated model to predict current and future Australian costs for people with dementia to help guide decision makers allocate scarce resources in the presence of capacity constraints (i.e. where the supply of resources does not meet demand). The model predicts an increase in costs for people with dementia from A$11.8 billion in 2015 to A$33.6 billion in 2050 at 2013–14 prices. If real per capita health and social expenditure increased by 1.0% annually, these costs are predicted to increase by around A$14.2 billion to a total of around A$47.8 billion by 2050. What are the implications for practitioners?: This simulation provides useful estimates of the potential future costs that will be borne for people with dementia and allows the exploration of the effects of capacity constraints on these costs. The model demonstrates that the level of real annual per capita growth in health and social expenditure has significant implications for the future sustainability of dementia care in Australia. [ABSTRACT FROM AUTHOR]

This paper provides an overview of quality improvement in healthcare in an Australian context. Specifically, the paper considers issues around defining, quantifying, recording and incentivising quality improvement and accountability in primary healthcare. The role of newly emerging Primary Health Networks provides a context for the discussion. The paper draws on international learnings that provide a framework for examining the important elements of quality improvement among reforming primary healthcare organisations in order to support healthcare providers and offer an evidence base for policy makers and peak bodies moving forward. [ABSTRACT FROM AUTHOR]

Nurses are increasingly needed in primary healthcare settings to support community-based healthcare delivery. Programs to facilitate transition of new graduate nurses are well established in acute care; however, there are few similar programs reported in settings like general practice. This paper sought to explore the experiences of new graduate registered nurses and their registered nurse mentors in a new graduate program within Australian general practice. New graduates (n = 9) and their mentors participated in interviews before, during and at the conclusion of a 12-month new graduate program. Interviews were digitally audio-recorded and professionally transcribed verbatim before being analysed using thematic analysis. Eighteen new graduate and 10 mentor interviews were conducted, revealing four themes. Preparation and Opportunities describes the influence that pre-registration education had on preparing nurses for general practice employment. Exceeding Expectations highlights the positive experiences within the program. Program Challenges draws attention to the difficulties experienced by participants, and Future Career Intentions explores future career plans. This study highlights that a general practice new graduate nurse program has the potential to build the workforce. However, strengthening undergraduate preparation of nurses around primary health care and addressing funding issues in general practice, are important to promote the success of such programs. [ABSTRACT FROM AUTHOR]

The launch of the third edition of the National guide to preventive health assessment for Aboriginal and Torres Strait Islander people in March 2018 heralds a renewed commitment to improving the delivery of preventive care, and should reinvigorate discussions on the effectiveness of Indigenous-specific health assessments and how best to implement them. A substantial body of evidence on adherence to guideline-recommended care has been generated through a research-based continuous quality improvement (CQI) initiative conducted between 2010 and 2014. The research, which involved clinical audits of more than 17 000 client records and 119 systems assessments relating to preventive care in 137 Indigenous primary healthcare centres across Australia, shows that a structured CQI program can improve the delivery of preventive health assessments and use of evidence-based guidelines. However, program implementation has also seen the emergence of new challenges. This paper reflects on four major lessons from this collaborative program of applied research that will lead to more effective delivery of preventive care. [ABSTRACT FROM AUTHOR]

Objectives: Any new model of care should always be accompanied by rigorous monitoring to ensure that there are no negative consequences, especially any that impact upon patient safety. In 2013, 'THERMoSTAT' (Two- Hour Evaluation and Referral Model for Shorter Turnaround Times), an emergency department model of care developed by Royal Brisbane and Women's Hospital staff was launched to gain efficiencies and improve hospital National Emergency Access Target (NEAT) compliance. The aim of this study was to trial the use of medical emergency call data as a novel marker of the quality of care delivered by our emergency department. Methods: Incidence of medical emergency calls for hospital emergency admission patients for the 2 years pre- and 1 year post-THERMoSTAT were compared after standardising for overall hospital activity. Results: During the study period, hospital activity increased 10%, and the emergency department experienced a total of 222 645 presentations, 68 000 (30.5%) of which converted into an admission. THERMoSTAT improved NEAT compliance by 17% (from 57.7% to 74.9%) with no change in any patient-safety indicators. A total of 8432 medical emergency calls were made on 5930 patients, 2831 of whom were emergency admissions. After adjusting for hospital activity, there was no change in the average number of patients per week who triggered a medical emergency call after the introduction of THERMoSTAT. These results were reproduced when data was analysed for: total number of inpatients triggering calls; emergency admission patients; and emergency admission patients within the first 24 h or first 4 h of admission. Conclusions: This is the first report to investigate the correlation between inpatient medical emergency call incidence and emergency department model of care. Medical emergency call data showed significant promise as a measure of morbidity and as a more direct, objective, simple, quantitative and meaningful measure of patient safety. What is known about the topic?: It is well established that extended emergency department lengths of stay are associated with poorer patient outcomes. The corollary of this is not always true however; shorter emergency department length of stay does not automatically translate into better care. Although the underlying philosophy of NEAT is to enhance patient care, there is a risk of negative consequences if NEAT is seen as an end in itself. Many of the commonly used emergency department key performance indicators focus on the timeliness of care and there is a scarcity of easily quantifiable markers that reliably reflect the quality of that care. What does this paper add?: This study builds on the concept of medical emergency call incidence as a marker of safety and quality. It explores the utility of using the number of medical emergency calls made in the first few hours of an emergency admission as an indicator of the quality of care delivered by the emergency department. This is significant because it introduces a measure that has a focus that embraces more than the timeliness of care only. What are the implications for practitioners?: If medical emergency call incidence in early emergency admissions can be proven to accurately reflect emergency department quality of care then it would provide an easily monitored, objective, quantitative and prompt measure that evaluates dimensions other than timeliness. [ABSTRACT FROM AUTHOR]

Care coordination models have developed in response to the recognition that Australia's health and welfare service system can be difficult to access, navigate and is often inefficient in caring for people with severe and persistent mental illness (SPMI) and complex care and support needs. This paper explores how the Australian Government's establishment of the Partners in Recovery (PIR) initiative provides an opportunity for the development of more effective and efficient models of coordinated care for the identified people with SPMI and their families and carers. In conceptualising how the impact of the PIR initiative could be maximised, the paper explores care coordination and what is known about current best practice. The key findings are the importance of having care coordinators who are well prepared for the role, can demonstrate competent practice and achieve better systemic responses focused on the needs of the client, thus addressing the barriers to effective care and treatment across complex service delivery systems. [ABSTRACT FROM AUTHOR]

Economic evaluation provides important evidence on value for money in health care and is routinely used in health technology assessment processes. The relevant costs and benefits of health care that are considered may arise now and/or in the future, and the relative importance placed on costs and benefits in the future is reflected in the discount rate applied to them. In this paper we note that Australia appears to apply one of the highest discount rates in the world to the assessment of future healthcare benefits. At a time when healthcare systems worldwide are calling for a rebalance of effort towards prevention, Australia's discount rate risks pulling resource allocation in precisely the opposite direction, locking in institutional short-sightedness to funding decisions. [ABSTRACT FROM AUTHOR]

The Australian health system performs well compared with other developed countries, but there is potential for improved health outcomes through the consideration of the opportunity costs of funding new health services. The opportunity costs of funding a new health service are the benefits forgone from the activities that would be funded if the new health service was not funded. When the forgone activity cannot be observed directly, the expected opportunity costs have been estimated as the expected gain in quality-adjusted life years (QALYs) associated with marginal increases in government expenditure on health. We have previously estimated that a gain of 1 QALY is expected for every additional A$28 033 of government expenditure on health. This paper discusses the relevance and proposed use of this estimate of opportunity costs to inform decisions around the public funding of new health services in Australia. [ABSTRACT FROM AUTHOR]

The digital transformation of hospitals in Australia is occurring rapidly in order to facilitate innovation and improve efficiency. Rapid transformation can cause temporary disruption of hospital workflows and staff as processes are adapted to the new digital workflows. The aim of this paper is to outline various types of digital disruption and some strategies for effective management.Alarge tertiary university hospital recently underwent a rapid, successful roll-out of an integrated electronic medical record (EMR). We observed this transformation and propose several digital disruption "syndromes" to assist with understanding and management during digital transformation: digital deceleration, digital transparency, digital hypervigilance, data discordance, digital churn and post-digital 'depression'. These 'syndromes' are defined and discussed in detail. Successful management of this temporary digital disruption is important to ensure a successful transition to a digital platform. [ABSTRACT FROM AUTHOR]