Search

Objective The aim of this study was to assess the unmet need for palliative and other end-of-life care, as well as the sociodemographic and diagnostic factors associated with suboptimal access, among residents in an Australian region. Methods A cross-sectional descriptive and analytical study was performed using non-identifiable linked data from four administrative and two clinical datasets. The study population comprised 3175 patients aged ≥15 years who died in hospital in 2016 and 2017. The main outcome measures were the proportion of decedents potentially benefitting from end-of-life care and receiving end-of-life care. Results An estimated 74.8% of decedents needed palliative or other end-of-life care in the year before death. Approximately 13.3% did not receive any end-of-life care despite its potential benefit. The highest proportions with 'unmet need' were decedents with chronic obstructive pulmonary disease (31.0%) and heart failure (26.3%). Adjusting for sociodemographic and diagnostic factors, access was lowest among those aged <65 years (adjusted odds ratio (aOR) 0.44; 95% confidence interval (CI) 0.31-0.64) and those with heart failure (aOR 0.58; 95% CI 0.47-0.72). Conclusions Estimates of need and access provide a sound basis for planning local palliative and end-of-life care services. These methods can be used on an ongoing basis to monitor service delivery. What is known about this topic? There is a small but expanding literature on estimating the need for palliative care at a population level. There is a lack of data regarding access to palliative and other end-of-life care across multiple settings (e.g. home, specialist palliative care unit, hospital) and patient groups (e.g. defined by sociodemographics and diagnostics). What does this paper add? The study builds on previously used methods for estimating the need for palliative care, with some refinements, including the addition of 'other clinical indications' and the use of weights to derive more realistic estimates. The estimates of need are consistent with recent estimates from Australia and overseas, whereas the estimates of access are similar to a recent Australian estimate, but higher than estimates from overseas. The gaps in access are highest among those with the major types of chronic organ failure, particularly heart and respiratory. What are the implications for practitioners? The study demonstrates how routinely collected data at a regional level can be used to estimate need and access to palliative and end-of-life care, in the hospital and in the community. These methods of estimating need and unmet need can be used to inform the planning and development of services, as well as to monitor progress with implementation of changes in service provision.

Objective To examine hospital use characteristics of a privately insured cohort including hospital setting (public or private), declared insurance status and category of services received during hospital admission. Methods The study population consisted of 14276 people with membership of a private health insurance (PHI) fund in New South Wales, Australia. The final study cohort included 9004 people with at least one hospital admission over a 6-year period from 1 January 2010 to 31 December 2015. PHI claims data were linked with public hospital records from a Local Health District. Hospital utilisation measures include number of admissions and length of stay. Measures were categorised by hospital user group (public only, private only or both), declared insurance status (PHI or public patient), type of service and admission case weight. Results The study finds that despite having PHI, 40% of people receive services exclusively in a public hospital in the 6-year study period. Additionally, only 62% of overnight hospital admissions for the study population are claimed on PHI. There are differences in hospital utilisation for medical- and surgical-related admissions. Seventy percent of people with a medical admission receive services only in public hospitals, but a similar proportion of people (66%) receive services only in private hospitals for surgical admissions. Conclusions People with PHI make considerable use of public hospitals both as a public and a private patient. For this privately insured cohort, public hospitals are more frequently used for medical-related admissions and also for more resource-intensive admissions compared with private hospitals. What is known about the topic? There are multiple government incentives to encourage people to take out PHI policies in Australia. Although PHI is closely associated with private hospital utilisation, people with PHI can still use public hospitals as either a public patient, in which the service is fully government-funded, or as a private patient in which PHI contributes funding towards the cost of hospital admissions. What does this paper add? This study provides the first analysis of hospital utilisation of a privately insured cohort in Australia that reports on the interaction between public and private hospital use and declared insurance status, including utilisation differences based on service type. What are the implications for practitioners? Although there are financial incentives offered by the Australian Government to encourage uptake of PHI, the study findings show that people with PHI still make considerable use of public hospitals both as a public and private patient. Future policy reforms relating to the regulation of PHI in Australia should consider the nuanced differences in the way people with PHI use public and private hospitals to optimise resource allocation.

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.

Objective This study explored the current activities of a sample of Australian private health insurance (PHI) funds to support the care of people living with chronic conditions, following changes to PHI legislation in 2007 permitting funds to cover a broader range of chronic disease management (CDM) services. Methods A qualitative research design was used to gather perspectives from PHI sector representatives via semistructured interviews with eight participants. The interview data were analysed systematically using the framework analysis method. Results Three main types of activities were most commonly identified: (1) healthcare navigation; (2) structured disease management and health coaching programs; and (3) care coordination services. These activities were primarily conducted via telephone by a combination of in-house and third-party health professionals. PHI funds seem to be taking a pragmatic approach to the type of CDM activities currently offered, guided by available data and identified member need. Activities are focused on people with diagnosed chronic conditions exiting hospital, rather than the broader population at-risk of developing a chronic condition. Conclusions Despite legislation permitting PHI funds to pay benefits for CDM services being in place for more than 10 years, insurers are still in an early stage of implementation and evaluation of CDM activities. Primarily due to the regulated scope of PHI coverage in Australia, participants reported several challenges in providing CDM services, including identifying target groups, evaluating service outcomes and collaborating with other healthcare providers. The effectiveness of the approach of PHI funds to CDM in terms of the groups targeted and outcomes of services provided still needs to be established because evidence suggests that population-level interventions that target a larger number of people with lower levels of risks are likely to have greater benefit than targeting a small number of high-risk cases. What is known about the topic? Since 2007, PHI funds in Australia have been able to pay benefits for a range of out-of-hospital services, focused on CDM. Although a small number of program evaluations has been published, there is little information on the scope of activities and the factors influencing the design and implementation of CDM programs. What does this paper add? This paper presents the findings of a qualitative study reporting on the CDM activities offered by a sample of PHI funds, their approach to delivery and the challenges and constraints in designing and implementing CDM activities, given the PHI sector's role as a supplementary health insurer in the Australian health system. What are the implications for practitioners? Current CDM activities offered by insurers focus on health navigation advice, structured, time-limited CDM programs and care coordination services for people following a hospital admission. There is currently little integration of these programs with the care provided by other health professionals for a person accessing these services. Although the role of insurers is currently small, the movement of insurers into service provision raises considerations for managing potential conflicts in having a dual role as an insurer and provider, including the effectiveness and value of services offered, and how these programs complement other types of health care being received.

Objective To develop and examine a profile of the demographic, hospital admission and clinical characteristics of high users of hospital resources within a cohort of privately insured Australians. Methods Hospital admissions claims data from a group of private health insurance funds were analysed. The top 1% of hospital users were selected based on three measures of resource utilisation: number of admissions, total bed days and total insurance benefits paid. The demographic, hospital admission and clinical characteristics data were compared for these three measures of resource utilisation. Results Compared with the general insured population, the three high-use cohorts are older, have more public hospital admissions and have more same-day admissions. The three high-use cohorts have the same top five principal diagnosis categories. These five categories account for more than two-thirds of admissions. The top 1% of users is responsible for a large proportion of total resource utilisation, accounting for 13% of total costs and 21% of total bed days. Conclusions The highest users of hospital resources have a distinct profile, accounting for a large proportion of total resource utilisation for a narrow range of health conditions. The age and hospital admission profile of this group suggest both policy and service considerations for the targeting of interventions to support this high-needs group. What is known about this topic? Statistics are regularly published on the uptake and use of private health insurance in Australia but there is little detailed information on resource utilisation in specific subgroups, particularly those with the highest levels of hospitalisation. What does this paper add? This paper provides a profile of high resource utilisation among a privately insured cohort, describing demographic, hospital admission and clinical characteristics across three measures of resource utilisation. Patterns of use are detailed in this profile, for example the top 1% of users have a higher proportion of public hospital admissions as a private patient. The clinical profile of admissions was similar for the three measures of resource utilisation and there was considerable overlap in the individuals categorised in each high-use group. What are the implications for practitioners? The narrow demographic and clinical profile of the high resource utilisation groups shows a chronic disease burden that is different to the focus of current chronic disease policy measures. The high-use conditions identified in this study are less amenable to preventive measures and new strategies may be required to target this high-needs group.

Objective: To determine whether there are real differences in emergency department (ED) performance between Australian states and territories., Methods: Cross-sectional analysis of 2009-10 attendances at an ED contributing to the Australian non-admitted patient ED care database. The main outcome measure was difference in waiting time across triage categories., Results: There were more than 5.8 million ED attendances. Raw ED waiting times varied by a range of factors including jurisdiction, triage category, geographic location and hospital peer group. All variables were significant in a model designed to test the effect of jurisdiction on ED waiting times, including triage category, hospital peer group, patient socioeconomic status and patient remoteness. When the interaction between triage category and jurisdiction entered the model, it was found to have a significant effect on ED waiting times (P<0.001) and triage was also significant (P<0.001). Jurisdiction was no longer statistically significant (P=0.248 using all triage categories and 0.063 using only Australian Triage Scale 2 and 3)., Conclusions: Although the Council of Australian Governments has adopted raw measures for its key ED performance indicators, raw waiting time statistics are misleading. There are no consistent differences in ED waiting times between states and territories after other factors are accounted for. WHAT IS KNOWN ABOUT THE TOPIC? The length of time patients wait to be treated after presenting at an ED is routinely used to measure ED performance. In national health agreements with the federal government, each state and territory in Australia is expected to meet waiting time performance targets for the five ED triage categories. The raw data indicate differences in performance between states and territories. WHAT DOES THIS PAPER ADD? Measuring ED performance using raw data gives misleading results. There are no consistent differences in ED waiting times between the states and territories after other factors are taken into account. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Judgements regarding differences in performance across states and territories for triage waiting times need to take into account the mix of patients and the mix of hospitals.

Objective: Examine demographics, clinical characteristics and rehabilitation outcomes of lower-limb amputees, using the Australasian Rehabilitation Outcomes Centre (AROC) database., Methods: Lower-limb amputee rehabilitation separations between 2004 and 2010 were identified using AROC impairment codes 5.3-5.7.(1) Analysis was conducted by year, impairment code, Australian National Sub-acute and Non-Acute Patient (AN-SNAP) classification (S2-224, Functional Independence Measure (FIM) motor(Mot) score 72-91; S2-225, FIM (Mot) score 14-71) and states of Australia., Results: Mean length of stay (LOS) for all lower-limb amputee episodes was 36.1 days (95% confidence interval (CI): 35.4-36.9). Majority of episodes were unilateral below knee (63.6%), males (71.8%) with a mean age of 67.9 years (95% CI: 67.6-68.3). Year-on-year analysis revealed a trend for increasing LOS and decreasing age. Analysis by impairment code demonstrated no significant difference in rehabilitation outcomes. Analysis by AN-SNAP found that LOS was 16.2 days longer for S2-225 than for S2-224 (95% CI: 14.7-17.8, P<0.001), and FIM (Mot) change was 12.0 points higher for S2-225 than for S2-224 (95% CI: 11.5-12.6, P<0.001). Analysis by states revealed significant variation in LOS, FIM (Mot) change and FIM (Mot) efficiency which may be associated with variations in organisation of rehabilitation services across states., Conclusion: Although amputees represented a comparatively small proportion of all rehabilitation episodes in Australia, their LOS was significant. Unlike many other rehabilitation conditions, there was no evidence of decreasing LOS over time. AN-SNAP classes were effective in distinguishing rehabilitation outcomes, and could potentially be used more effectively in planning rehabilitation programs.

Objective: This study explores the views of senior managers regarding their experience of participating in the Clinical Services Redesign Program (CSRP) in New South Wales and the impact of that Program., Methods: Semi-structured interviews were conducted in 2007 with 42 senior managers working in the NSW health system., Results: Managers reported being increasingly oriented towards efficiency, achieving results and using data to support decision-making. The increased focus on managing performance was accompanied by concerns about the narrowness of the indicators being used to manage performance and how these are applied. The value placed by interviewees on the use of 'competition' as a lever for improving services varied. Leadership was repeatedly identified as important for long-term success and sustainability. No one was confident that the CSRP had yet been sufficiently embedded in day to day practice in order for it to keep going on its own., Conclusion: Our findings are generally consistent with the extensive literature on change management, performance management and leadership. Some cultural change has taken place in terms of observed patterns of behaviour but it is unrealistic to think that CSRP can on its own deliver the desired deeper cultural changes in the values and assumptions underpinning the NSW Health system. There is some evidence of dysfunctional aspects of performance management but no call for the focus on performance or redesign to be abandoned.

Australia is leading the way in establishing a national system (the Palliative Care Outcomes Collaboration - PCOC) to measure the outcomes and quality of specialist palliative care services and to benchmark services across the country. This article reports on analysis of data collected routinely at point-of-care on 5939 patients treated by the first fifty one services that voluntarily joined PCOC. By March 2009, 111 services have agreed to join PCOC, representing more than 70% of services and more than 80% of specialist palliative care patients nationally. All states and territories are involved in this unique process that has involved extensive consultation and infrastructure and close collaboration between health services and researchers. The challenges of dealing with wide variation in outcomes and practice and the progress achieved to date are described. PCOC is aiming to improve understanding of the reasons for variations in clinical outcomes between specialist palliative care patients and differences in service outcomes as a critical step in an ongoing process to improve both service quality and patient outcomes.

Primary care presentations at emergency departments (EDs) have been the subject of much attention in recent years. This paper is a demographic analysis using administrative data from the Emergency Department Information System (EDIS) for 2005 of such presentations in New South Wales EDs and of self-reported reasons for presentation. Age and sex differences in the reasons given by patients for such presentations are analysed using data from a survey of patients conducted in a subset of EDs in 2004. The rate of "potential primary care" presentations varies greatly with age and to a lesser extent with sex. Almost half (47%) of these presentations are made by people under 25 years of age. Children aged 0-4 years account for 14% of the total. The pattern is distinctly different to the corresponding rate of ED presentations that do not fit the "potential primary care" definition. Reasons given for "potential primary care" presentations are consistent across all age groups, reflecting self-assessed urgency, access to diagnostics and self-assessed complexity. Older "primary care" patients are particularly unlikely to give reasons associated with GP affordability or availability for their presentations. Young adults' responses are consistent with the overall population, and children under the age of five seem most susceptible to availability issues.

Providing information technology solutions to clinicians to support their work practices benefits clinicians, administrators and patients. We present our 8-year experience with an inexpensive information management system which provides clinical and business process support for clinicians and bed managers. The system has been used by an area rehabilitation and aged care service to manage inpatient consultations and patient flow across nine hospitals. Performance monitoring of the time from referral to consultation, the number, type and outcome of consultations, and the time taken to access a rehabilitation or subacute bed is also provided. Read-only access to the system for clinicians and bed managers outside the rehabilitation and aged care service allows greater transparency.

Aims and Methods: We piloted the InterQual Criteria tool in a large regional acute hospital in NSW to determine the utility of this tool in the Australian context. In particular to compare the current "gold standard" of physician assessment for the selection of patients for rehabilitation and the timing of transfer, with the guidance provided by the tool. Consecutive acute care patients with a diagnosis of stroke, hip fracture or amputation, and patients referred for rehabilitation assessment, were followed using the InterQual Criteria., Results: Results on 242 acute episodes, representing 2698 days in acute care, were analysed. In accordance with overseas studies, we found that high levels of inappropriate days of stay in acute care were suggested by the tool. Using the InterQual Criteria almost all patients were deemed appropriate for transfer to rehabilitation much earlier than current practice., Conclusion: We conclude that the InterQual Criteria may have a useful role in patient selection for rehabilitation, in facilitating the transfer of patients from acute to subacute care, and in improving patient flow within acute care. The reasons for the variation between the results obtained from the tool and current clinical practice requires further investigation, and may indicate a lack of validity of the tool in the Australian setting, inefficiencies in processes of acute care, or the lack of suitable alternative care settings or level of support available in these settings.

Aims: To describe and measure differences between ethnic groups on standard measures of mental health outcome., Methods: Clinical staff in eight New Zealand Health Districts collected consumer outcomes data at the start, end and review of episodes of care. Consumers were allocated to one of three ethnicity groupings -- Maori, Pacific Island and "All Other"., Results: There were large differences between the three ethnicity groupings on the measures. Maori and Pacific Island consumers appeared to demonstrate more psychotic phenomena and overall worse scores, and the All Other group, more depression. Changes in scores between start and end of episodes of care were proportionately similar across the three groups. Differences between ethnic groupings varied according to socio-economic deprivation level., Conclusions: Potential reasons for some of the effects observed are discussed, including differing pathways to care, clinician and selection bias, and differing models of mental health.

Three projects were funded under the national Mental Health Integration Program (MHIP) in 1999, each of which employed a different model aimed at improving linkages between disparate parts of the mental health system. A national evaluation framework guided local evaluations of these projects, and this paper presents a synthesis of the findings. For providers, the projects improved working relationships, created learning opportunities and increased referral and shared care opportunities. For consumers and carers, the projects resulted in a greater range of options and increased continuity of care. For the wider system, the projects achieved significant structural and cultural change. Cost-wise, there were no increases in expenditure, and even some reductions. Many of the lessons from the projects (and their evaluations) may be generalised to other mental health settings and beyond.

This paper evaluates training in the use of measures of outcomes and casemix provided to four pilot agencies in Victoria, Australia. The training program is outlined along with key evaluation findings. The knowledge and skills of participants developed during training is described. Deficiencies in the training program are identified and opportunities for improvement outlined.

The routine assessment of client outcomes was set as an objective in the Australian National Mental Health Policy in 1992. Victoria was the first jurisdiction to begin the implementation. This paper reports this process, and describes the background to outcome measurement in mental health, assembly of the implementation team, certain key concepts, development of the training materials, the approach to training, and a brief description of the evaluation. We end with a number of observations and recommendations that arose out of the project.