Australian Genomics: Outcomes of a 5-year national program to accelerate the integration of genomics in healthcare.

Australian Genomics is a national collaborative partnership of more than 100 organizations piloting a whole-of-system approach to integrating genomics into healthcare, based on federation principles. In the first five years of operation, Australian Genomics has evaluated the outcomes of genomic testing in more than 5,200 individuals across 19 rare disease and cancer flagship studies. Comprehensive analyses of the health economic, policy, ethical, legal, implementation and workforce implications of incorporating genomics in the Australian context have informed evidence-based change in policy and practice, resulting in national government funding and equity of access for a range of genomic tests. Simultaneously, Australian Genomics has built national skills, infrastructure, policy, and data resources to enable effective data sharing to drive discovery research and support improvements in clinical genomic delivery.

Progress with the Learning Health System 2.0: a rapid review of Learning Health Systems' responses to pandemics and climate change.

BACKGROUND: Pandemics and climate change each challenge health systems through increasing numbers and new types of patients. To adapt to these challenges, leading health systems have embraced a Learning Health System (LHS) approach, aiming to increase the efficiency with which data is translated into actionable knowledge. This rapid review sought to determine how these health systems have used LHS frameworks to both address the challenges posed by the COVID-19 pandemic and climate change, and to prepare for future disturbances, and thus transition towards the LHS2.0. METHODS: Three databases (Embase, Scopus, and PubMed) were searched for peer-reviewed literature published in English in the five years to March 2023. Publications were included if they described a real-world LHS's response to one or more of the following: the COVID-19 pandemic, future pandemics, current climate events, future climate change events. Data were extracted and thematically analyzed using the five dimensions of the Institute of Medicine/Zurynski-Braithwaite's LHS framework: Science and Informatics, Patient-Clinician Partnerships, Continuous Learning Culture, Incentives, and Structure and Governance. RESULTS: The search yielded 182 unique publications, four of which reported on LHSs and climate change. Backward citation tracking yielded 13 additional pandemic-related publications. None of the climate change-related papers met the inclusion criteria. Thirty-two publications were included after full-text review. Most were case studies (n = 12, 38%), narrative descriptions (n = 9, 28%) or empirical studies (n = 9, 28%). Science and Informatics (n = 31, 97%), Continuous Learning Culture (n = 26, 81%), Structure and Governance (n = 23, 72%) were the most frequently discussed LHS dimensions. Incentives (n = 21, 66%) and Patient-Clinician Partnerships (n = 18, 56%) received less attention. Twenty-nine papers (91%) discussed benefits or opportunities created by pandemics to furthering the development of an LHS, compared to 22 papers (69%) that discussed challenges. CONCLUSIONS: An LHS 2.0 approach appears well-suited to responding to the rapidly changing and uncertain conditions of a pandemic, and, by extension, to preparing health systems for the effects of climate change. LHSs that embrace a continuous learning culture can inform patient care, public policy, and public messaging, and those that wisely use IT systems for decision-making can more readily enact surveillance systems for future pandemics and climate change-related events. TRIAL REGISTRATION: PROSPERO pre-registration: CRD42023408896.

The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study).

BACKGROUND: This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. METHODS: Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. RESULTS: Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. CONCLUSIONS: This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

The Australian Genomics Mitochondrial Flagship: A National Program Delivering Mitochondrial Diagnoses.

PURPOSE: Families living with mitochondrial diseases (MD) often endure prolonged diagnostic journeys and invasive testing, yet many remain without a molecular diagnosis. The Australian Genomics Mitochondrial flagship, comprising clinicians, diagnostic, and research scientists, conducted a prospective national study to identify the diagnostic utility of singleton genomic sequencing using blood samples. METHODS: 140 children and adults living with suspected MD were recruited using modified Nijmegen criteria (MNC) and randomized to either exome + mtDNA sequencing (ES+mtDNAseq) or genome sequencing (GS). RESULTS: Diagnostic yield was 55% (n=77) with variants in nuclear (n=37) and mtDNA (n=18) MD genes, as well as phenocopy genes (n=22). A nuclear gene etiology was identified in 77% of diagnoses, irrespective of disease onset. Diagnostic rates were higher in pediatric-onset (71%) than adult-onset (31%) cases, and comparable in children with non-European (78%) versus European (67%) ancestry. For children, higher MNC scores correlated with increased diagnostic yield and fewer diagnoses in phenocopy genes. Additionally, three adult patients had a mtDNA deletion discovered in skeletal muscle that was not initially identified in blood. CONCLUSION: Genomic sequencing from blood can simplify the diagnostic pathway for individuals living with suspected MD, especially those with childhood onset diseases and high MNC scores.

Group-based trajectories of potentially preventable hospitalisations among older adults after a hip fracture.

Key predictors of three trajectory group membership of potentially preventable hospitalisations were age, the number of comorbidities, the presence of chronic obstructive pulmonary disease and congestive heart failure, and frailty risk at the occurrence of hip fracture. These predictors of their trajectory group could be used in targeting prevention strategies. PURPOSE: Although older adults with hip fracture have a higher risk of multiple readmissions after index hospitalisation, little is known about potentially preventable hospitalisations (PPH) after discharge. This study examined group-based trajectories of PPH during a five-year period after a hip fracture among older adults and identified factors predictive of their trajectory group membership. METHODS: This retrospective cohort study was conducted using linked hospitalisation and mortality data in New South Wales, Australia, between 2013 and 2021. Patients aged ≥ 65 years who were admitted after a hip fracture and discharged between 2014 and 2016 were identified. Group-based trajectory models were derived based on the number of subsequent PPH following the index hospitalisation. Multinominal logistic regression examined factors predictive of trajectory group membership. RESULTS: Three PPH trajectory groups were revealed among 17,591 patients: no PPH (89.5%), low PPH (10.0%), and high PPH (0.4%). Key predictors of PPH trajectory group membership were age, number of comorbidities, dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), frailty risk, place of incident, surgery, rehabilitation, and length of hospital stay. The high PPH had a higher proportion of patients with ≥ 2 comorbidities (OR: 1.86, 95% confidence interval (CI): 1.04-3.32) and COPD (OR: 2.97, 95%CIs: 1.76-5.04) than the low PPH, and the low and high PPHs were more likely to have CHF and high frailty risk as well as ≥ 2 comorbidities and COPD than the no PPH. CONCLUSIONS: Identifying trajectories of PPH after a hip fracture and factors predictive of trajectory group membership could be used to target strategies to reduce multiple readmissions.

Four System Enablers of Large-System Transformation in Health Care: A Mixed Methods Realist Evaluation.

Policy Points The implementation of large-scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge. Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture. Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. CONTEXT: Large-scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large-scale transformation in health care systems. METHODS: A realist study of the implementation of a value-based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context-mechanism-outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. FINDINGS: Forty-two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large-system transformation that illustrates when, for whom, and in what circumstances large-system transformation worked well or worked poorly. CONCLUSIONS: System enablers offer nuanced guidance for the implementation of large-scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large-system value-based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care.

Operationalisation of health equity principles in physiotherapy hospital triage policies.

BACKGROUND: Healthcare triage policies are vital for allocating limited resources fairly and equitably. Despite extensive studies of healthcare equity, consensus on the applied definition of equity in triage remains elusive. This study aimed to investigate how the principles of equity are operationalised in Australian hospital physiotherapy triage tools to guide resource distribution. METHODS: A retrospective, qualitative content analysis of 13 triage policies from 10 hospitals across Australia was conducted. Triage policies from both inpatient and outpatient settings were sourced. Data were coded deductively using the five discrete domains of the multi-faceted operational definition of health equity posited by Lane et al. (2017): 1) point of equalisation in the health service supply/access/outcome chain, 2) need or potential to benefit, 3) groupings of equalisation, 4) caveats to equalisation, 5) close enough is good enough. Descriptive summative statistics were used to analyse and present the frequency of reported equity domains. RESULTS: Within the included triage tools, four out of five domains of equity were evident in the included documents to guide decision making. Allocation based on perceived patient need and overall health outcomes were the central guiding principles across both inpatient and outpatient settings. Equal provision of service relative to patient need and reducing wait times were also prioritised. However, explicit inclusion of certain equity domains such as discrimination, ensuring equal capability to be healthy and other patient factors was limited. CONCLUSIONS: Physiotherapy triage policies consider various domains of equity to guide resource allocation decisions. Policymakers and service providers can use the insights gained from this study to review the application and operationalisation of equity principles within their healthcare systems through mechanisms such as patient triage tools.

Beyond the aspirational: creating the future of health care in Australia.

The context of health care in Australia is shifting very rapidly; more chronic diseases, budgetary stress and the constant threat of the next pandemic and climate change mean that patterns of disease and care are changing, and the workforce is under pressure. Health systems have learned to respond as best they can, but there are many challenges and opportunities for the Australian health care system to plan and implement an evidence-based and sustainable approach to health care delivery in the next decade. To support this approach, many peak bodies and authoritative agencies, such as the Australian government in their 2022 Strengthening Medicare Taskforce Report, have described laudable visions for health care, but no one has laid out a tangible blueprint for whole-of-system change. Here, we outline nine strategies that span principles of integrated, value-based care, with a focus on prevention and quality, the development of a skilled workforce and health-literate population and the use of emerging technologies such as genomics and artificial intelligence. These strategies form a potential path for the Australian health care system to meet the changing requirements of the current decade and take the aspirational visions of the future of health care into an improved, patient-based health system that delivers care in line with best practices.

What Australia must do to create a climate-responsive health system.

COP-28, the United Nations' Climate Change Conference, hosted by the United Arab Emirates, ended on 12 December 2023. At the convention, Australia released its National Health and Climate Strategy, committing to low-carbon, climate-responsive care. The Strategy will need new policies, projects and investments and a fit-for-purpose health workforce. This is a tall order considering healthcare's challenges. Everyone has a role, including clinicians, healthcare agencies, policymakers, politicians, patients and the providers and manufacturers in the supply chain. Clinicians' groups, policymakers and federal and state departments of health have an opportunity to lead climate change reform by considering climate change impacts across clinical practice and health policy.

Factors affecting 12-month unplanned readmissions for chronic obstructive pulmonary disease patients: the effect of mental disorders in an Australian cohort.

BACKGROUND: Many individuals with chronic obstructive pulmonary disease (COPD) experience frequent hospitalization and readmissions, which is burdensome on the health system. This study aims to investigate factors associated with unplanned readmissions and mortality following a COPD-related hospitalization over a 12-month period in Australia, focusing on mental disorders and accounting for the acute phase of the COVID-19 pandemic. METHODS: A retrospective cohort study using linked hospitalization and mortality records identified individuals aged ≥40 years who had at least one hospital admission with a principal diagnosis of COPD between 2014 and 2020 in New South Wales, Australia. A semi-competing risk analysis was conducted to examine factors associated with unplanned readmission and mortality. RESULTS: Adults with a mental disorder diagnosis, specifically anxiety, had a higher risk of 12-month unplanned readmission. Individuals with anxiety and dementia also had a higher risk of mortality pre- and post-unplanned readmission. Individuals who were admitted during the acute phase of the COVID-19 pandemic period had lower risk of unplanned readmission, but higher risk of mortality without unplanned readmission. CONCLUSION: Interventions aimed at reducing admissions should consider adults living with mental disorders such as anxiety or dementia to improve healthcare delivery and health outcomes for individuals living with COPD.

'No matter what time of day': The value of joining Facebook groups supporting women's self-management of gestational diabetes mellitus.

BACKGROUND: Gestational diabetes mellitus (GDM) affects a significant and growing proportion of pregnant women each year. The condition entails additional monitoring, self-management and healthcare use during pregnancy, and some women also join GDM support groups on Facebook. Little is known about the practices inside these groups, but examining them may elucidate support needs, women's experience of healthcare and improve overall outcomes. The aims of this study were to explore motivations for joining GDM Facebook groups and the perceived value and benefits of such spaces. DESIGN: A cross-sectional design using a web-based survey collected data from two peer-led GDM Facebook groups; relevant quantitative and qualitative data were extracted from open and closed questions, and analysed using descriptive statistics and content analysis. RESULTS: A total of 340 women responded to the survey, with 306 (90%) tendering their motivations to join a GDM Facebook group. Their answers were classified into six categories: peer support; information and practical advice; lived experiences; community; a safe place to ask questions and being recommended. The most commonly reported benefits of membership were 'reading about food ideas' and 'finding helpful information and tips'. Respondents reported finding their group strongly sympathetic, sincere, compassionate, heart-felt, tolerant, sensitive, warm and supportive. DISCUSSION AND CONCLUSIONS: GDM Facebook groups are valuable for informational and emotional support, and the sharing and perusal of lived experiences; another key benefit for women is feeling belonging to a community. GDM Facebook groups provide women with access to more tailored and readily available support, filling gaps not addressed by healthcare providers. PATIENT CONTRIBUTION: This study was led by a person with lived experience of GDM, and the survey was pilot tested with women who had also experienced GDM, which contributed to its development.

Public Perceptions of the Australian Health System During COVID-19: Findings From a 2021 Survey Compared to Four Previous Surveys.

BACKGROUND: This study examines the perceptions of the Australian public canvassed in 2021 during the COVID-19 pandemic about their health system compared to four previous surveys (2008, 2010, 2012 and 2018). METHODS: In 2021, a nationwide online survey was conducted with a representative sample of Australians (N = 5100) recruited via market research panels. The results were compared to previous nationwide Australian survey samples from 2018 (N = 1024), 2012 (N = 1200), 2010 (N = 1201) and 2008 (N = 1146). The survey included questions consistent with previous polls regarding self-reported health status and overall opinions of, and confidence in, the Australian health system. RESULTS: There was an increase in the proportion of respondents reporting positive perceptions at each survey between 2008 and 2021, with a significantly higher proportion of respondents expressing a more positive view of the Australian healthcare system in 2021 compared to previous years (χ2(8, N = 9645) = 487.63, p < 0.001). In 2021, over two-thirds of respondents (n = 3949/5100, 77.4%) reported that following the COVID-19 pandemic, their confidence in the Australian healthcare system had either remained the same (n = 2433/5100, 47.7%) or increased (n = 1516/5100, 29.7%). Overall, respondents living in regional or remote regions, younger Australians (< 45 years) and women held less positive views in relation to the system. In 2021, the most frequently identified area for urgent improvement was the need for more healthcare workers (n = 1350/3576, 37.8%), an area of concern particularly for Australians residing in regional or remote areas (n = 590/1385, 42.6%). CONCLUSIONS: Irrespective of disruptions to the Australian healthcare system caused by the COVID-19 pandemic, Australians' perceptions of their healthcare system were positive in 2021. However, concerns were raised about inadequate workforce capacity and the cost of healthcare, with differences identified by age groups and geographical location. PATIENT OR PUBLIC CONTRIBUTION: Health consumer representatives from the Consumers Health Forum of Australia contributed to the co-design, deployment, analysis and interpretation of the results of this survey. J.A. and L.W. from the Consumers Health Forum of Australia contributed to the development of the paper.

Benefits, implementation and sustainability of innovative paediatric models of care for children with type 1 diabetes: a systematic review.

BACKGROUND AND AIM: The evidence about the acceptability and effectiveness of innovative paediatric models of care for Type 1 diabetes is limited. To address this gap, we synthesised literature on implemented models of care, model components, outcomes, and determinants of implementation and sustainability. METHODS: A systematic review was conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Database searches of Medline, CINAHL, EMBASE and Scopus were conducted. Empirical studies focused on Type 1 diabetes paediatric models of care, published from 2010 to 2022 in English were included. RESULTS: Nineteen extant studies reported on models and their associations with health and psychosocial outcomes, patient engagement with healthcare, and healthcare costs. Thirteen studies described multidisciplinary teamwork, education and capacity building that supported self-care. Four studies involved shared decision making between providers and patients, and two discussed outreach support where technology was an enabler. Fourteen studies reported improvements in health outcomes (e.g. glycaemic control), mostly for models that included multidisciplinary teams, education, and capacity building (11 studies), outreach support or shared care (3 studies). Four studies reported improvements in quality of life, three reported increased satisfaction for patients and carers and, and one reported improved communication. Four of five studies describing shared care and decision-making reported improvements in quality of life, support and motivation. Outreach models reported no negative outcomes, however, accessing some models was limited by technological and cost barriers. Eight studies reported on model sustainability, but only half reported implementation determinants; none reported applying a theoretical framework to guide their research. CONCLUSION: Some health and psychosocial benefits were associated with newer models. To address knowledge gaps about implementation determinants and model sustainability, longitudinal studies are needed to inform future adoption of innovative models of care for children with Type 1 diabetes.

Learning health systems on the front lines to strengthen care against future pandemics and climate change: a rapid review.

BACKGROUND: An essential component of future-proofing health systems against future pandemics and climate change is strengthening the front lines of care: principally, emergency departments and primary care settings. To achieve this, these settings can adopt learning health system (LHS) principles, integrating data, evidence, and experience to continuously improve care delivery. This rapid review aimed to understand the ways in which LHS principles have been applied to primary care and emergency departments, the extent to which LHS approaches have been adopted in these key settings, and the factors that affect their adoption. METHODS: Three academic databases (Embase, Scopus, and PubMed) were searched for full text articles reporting on LHSs in primary care and/or emergency departments published in the last five years. Articles were included if they had a primary focus on LHSs in primary care settings (general practice, allied health, multidisciplinary primary care, and community-based care) and/or emergency care settings. Data from included articles were catalogued and synthesised according to the modified Institute of Medicine's five-component framework for LHSs (science and informatics, patient-clinician partnerships, incentives, continuous learning culture, and structure and governance). RESULTS: Thirty-seven articles were included, 32 of which reported LHSs in primary care settings and seven of which reported LHSs in emergency departments. Science and informatics was the most commonly reported LHS component, followed closely by continuous learning culture and structure and governance. Most articles (n = 30) reported on LHSs that had been adopted, and many of the included articles (n = 17) were descriptive reports of LHS approaches. CONCLUSIONS: Developing LHSs at the front lines of care is essential for future-proofing against current and new threats to health system sustainability, such as pandemic- and climate change-induced events. Limited research has examined the application of LHS concepts to emergency care settings. Implementation science should be utilised to better understand the factors influencing adoption of LHS approaches on the front lines of care, so that all five LHS components can be progressed in these settings.

Evaluation of a culture change program to reduce unprofessional behaviours by hospital co-workers in Australian hospitals.

BACKGROUND: Unprofessional behaviours between healthcare workers are highly prevalent. Evaluations of large-scale culture change programs are rare resulting in limited evidence of intervention effectiveness. We conducted a multi-method evaluation of a professional accountability and culture change program "Ethos" implemented across eight Australian hospitals. The Ethos program incorporates training for staff in speaking-up; an online system for reporting co-worker behaviours; and a tiered accountability pathway, including peer-messengers who deliver feedback to staff for 'reflection' or 'recognition'. Here we report the final evaluation component which aimed to measure changes in the prevalence of unprofessional behaviours before and after Ethos. METHODS: A survey of staff (clinical and non-clinical) experiences of 26 unprofessional behaviours across five hospitals at baseline before (2018) and 2.5-3 years after (2021/2022) Ethos implementation. Five of the 26 behaviours were classified as 'extreme' (e.g., assault) and 21 as incivility/bullying (e.g., being spoken to rudely). Our analysis assessed changes in four dimensions: work-related bullying; person-related bullying; physical bullying and sexual harassment. Change in experience of incivility/bullying was compared using multivariable ordinal logistic regression. Change in extreme behaviours was assessed using multivariable binary logistic regression. All models were adjusted for respondent characteristics. RESULTS: In total, 3975 surveys were completed. Staff reporting frequent incivility/bullying significantly declined from 41.7% (n = 1064; 95% CI 39.7,43.9) at baseline to 35.5% (n = 505; 95% CI 32.8,38.3; χ2(1) = 14.3; P < 0.001) post-Ethos. The odds of experiencing incivility/bullying declined by 24% (adjusted odds ratio [aOR] 0.76; 95% CI 0.66,0.87; P < 0.001) and odds of experiencing extreme behaviours by 32% (aOR 0.68; 95% CI 0.54,0.85; P < 0.001) following Ethos. All four dimensions showed a reduction of 32-41% in prevalence post-Ethos. Non-clinical staff reported the greatest decrease in their experience of unprofessional behaviour (aOR 0.41; 95% CI 0.29, 0.61). Staff attitudes and reported skills to speak-up were significantly more positive at follow-up. Awareness of the program was high (82.1%; 95% CI 80.0, 84.0%); 33% of respondents had sent or received an Ethos message. CONCLUSION: The Ethos program was associated with significant reductions in the prevalence of reported unprofessional behaviours and improved capacity of hospital staff to speak-up. These results add to evidence that staff will actively engage with a system that supports informal feedback to co-workers about their behaviours and is facilitated by trained peer messengers.

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

BACKGROUND: This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change. METHODS: We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. RESULTS: CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. CONCLUSIONS: A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Is it possible to make 'living' guidelines? An evaluation of the Australian Living Stroke Guidelines.

BACKGROUND: Keeping best practice guidelines up-to-date with rapidly emerging research evidence is challenging. 'Living guidelines' approaches enable continual incorporation of new research, assisting healthcare professionals to apply the latest evidence to their clinical practice. However, information about how living guidelines are developed, maintained and applied is limited. The Stroke Foundation in Australia was one of the first organisations to apply living guideline development methods for their Living Stroke Guidelines (LSGs), presenting a unique opportunity to evaluate the process and impact of this novel approach. METHODS: A mixed-methods study was conducted to understand the experience of LSGs developers and end-users. We used thematic analysis of one-on-one semi-structured interview and online survey data to determine the feasibility, acceptability, and facilitators and barriers of the LSGs. Website analytics data were also reviewed to understand usage. RESULTS: Overall, the living guidelines approach was both feasible and acceptable to developers and users. Facilitators to use included collaboration with multidisciplinary clinicians and stroke survivors or carers. Increased workload for developers, workload unpredictability, and limited information sharing, and interoperability of technological platforms were identified as barriers. Users indicated increased trust in the LSGs (69%), likelihood of following the LSGs (66%), and frequency of access (58%), compared with previous static versions. Web analytics data showed individual access by 16,517 users in 2016 rising to 53,154 users in 2020, a threefold increase. There was also a fourfold increase in unique LSG pageviews from 2016 to 2020. CONCLUSIONS: This study, the first evaluation of living guidelines, demonstrates that this approach to stroke guideline development is feasible and acceptable, that these approaches may add value to developers and users, and may increase guideline use. Future evaluations should be embedded along with guideline implementation to capture data prospectively.

Potentially burdensome care at the end-of-life for cancer decedents: a retrospective population-wide study.

BACKGROUND: Variation persists in the quality of end-of-life-care (EOLC) for people with cancer. This study aims to describe the characteristics of, and examine factors associated with, indicators of potentially burdensome care provided in hospital, and use of hospital services in the last 12 months of life for people who had a death from cancer. METHOD: A population-based retrospective cohort study of people aged ≥ 20 years who died with a cancer-related cause of death during 2014-2019 in New South Wales, Australia using linked hospital, cancer registry and mortality records. Ten indicators of potentially burdensome care were examined. Multinominal logistic regression examined predictors of a composite measure of potentially burdensome care, consisting of > 1 ED presentation or > 1 hospital admission or ≥ 1 ICU admission within 30 days of death, or died in acute care. RESULTS: Of the 80,005 cancer-related deaths, 86.9% were hospitalised in the 12 months prior to death. Fifteen percent had > 1 ED presentation, 9.9% had > 1 hospital admission, 8.6% spent ≥ 14 days in hospital, 3.6% had ≥ 1 intensive care unit admission, and 1.2% received mechanical ventilation on ≥ 1 occasion in the last 30 days of life. Seventeen percent died in acute care. The potentially burdensome care composite measure identified 20.0% had 1 indicator, and 10.9% had ≥ 2 indicators of potentially burdensome care. Compared to having no indicators of potentially burdensome care, people who smoked, lived in rural areas, were most socially economically disadvantaged, and had their last admission in a private hospital were more likely to experience potentially burdensome care. Older people (≥ 55 years), females, people with 1 or ≥ 2 Charlson comorbidities, people with neurological cancers, and people who died in 2018-2019 were less likely to experience potentially burdensome care. Compared to people with head and neck cancer, people with all cancer types (except breast and neurological) were more likely to experience ≥ 2 indicators of potentially burdensome care versus none. CONCLUSION: This study shows the challenge of delivering health services at end-of-life. Opportunities to address potentially burdensome EOLC could involve taking a person-centric approach to integrate oncology and palliative care around individual needs and preferences.

Determinants of women's agency in accessing and utilising reproductive healthcare services; a systematic review.

Women's agency is vital to access and use reproductive healthcare services, particularly in contexts where patriarchal beliefs and cultural norms limit women's desire to act on their goals or affect their access to essential resources. However, less is known about what resources enable women to exercise agency to access these services. A comprehensive systematic review was conducted to summarise existing evidence on the determinants of women's agency in accessing and using reproductive healthcare services. Various determinants were identified, including individual characteristics; household structure; reproductive health-related determinants; social relations; and economic factors. These determinants of women's agency in accessing reproductive healthcare services were strongly associated with social norms and cultural beliefs. Several gaps in the literature included inconsistent definitions and measurement of women's agency; lack of considering cultural sensitivities and socially acceptable practices in the conceptualisation and measurement of women's agency; a narrow focus on services related predominantly to pregnancy and birth, with other aspects of services including sexual health and safe abortion being largely unreported. The literature focused on developing countries in Africa and Asia, leaving a significant gap in knowledge about women's agency to access services in other geographical areas or among immigrant or refugee populations living in developed countries.

The Unintended Consequences of Telehealth in Australia: Critical Interpretive Synthesis.

BACKGROUND: Despite more than 2 decades of telehealth use in Australia and the rapid uptake during the COVID-19 pandemic, little is known about its unintended consequences beyond its planned and intended outcomes. OBJECTIVE: The aim of this review was to synthesize evidence on the unintended consequences of telehealth use in Australia to clarify its impact beyond its planned and intended outcomes. METHODS: We conducted a search of 4 electronic databases: Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and Scopus. A critical interpretive synthesis approach was adopted for its flexibility and interpretive nature. We extracted data about study characteristics and the types and models of telehealth services. The extracted unintended consequences were coded and mapped into the domains and dimensions of the Australian Health Performance Framework. RESULTS: Of the 4241 records identified by the search, 94 (2.22%) studies were eligible for data extraction and analysis. Of these 94 studies, 23 (24%) reported largely positive unintended consequences of telehealth associated with health status, while 6 (6%) noted a potential negative impact of telehealth on socioeconomic status. The findings of 4 (4%) of the 94 studies highlighted societal and financial consequences of telehealth beyond the health system. Almost all studies (93/94, 99%) reported unintended consequences under the 5 dimensions of the Australian Health Performance Framework. CONCLUSIONS: Our synthesis offers a framework for understanding the unintended consequences of the use of telehealth as an alternative to in-person care in Australia. While we have documented many unintended benefits of telehealth use, our findings also shed light on many challenges of delivering care via telehealth across different domains and dimensions. These findings hold significant practice and policy-making implications for ensuring safe and high-quality care delivery via telehealth.