Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data.

OBJECTIVE: To investigate inpatient rehabilitation rates after private total knee replacements (TKRs) in Australia since 2009; to quantify the contributions of hospital-, surgeon- and patient-related factors to predicting inpatient rehabilitation. DESIGN: Retrospective cohort study; multivariate linear regression analysis of linked, de-identified Medibank administrative claims data and hospital casemix protocol data, adjusted for patient-related characteristics. Setting, participants: 35 389 patients undergoing Medibank-funded TKRs in 170 private hospitals in Australia, 2009-2016. MAIN OUTCOME MEASURES: Hospital inpatient rehabilitation rate; relative contributions of patient- and provider-related characteristics to variation in inpatient rehabilitation rates. RESULTS: The overall inpatient rehabilitation rate increased from 31% in 2009 to 45% in 2016, but varied between hospitals (range, 0-100%). The reduction in mean acute length of stay during this period explained about 15% of this increase, and about 30% was explained by patient-related factors; more than half of the increase was explained by neither reduced length of stay or patient-related factors. Patient-related characteristics explained little of the variation in rates between hospitals. Rates at 27% of hospitals lay above the 95% confidence limit for the mean inpatient rehabilitation rate in private hospitals (38%), both before and after adjusting for patient-related factors. Provider characteristics explained three times as much of the variation as patient characteristics (75% v 25%); hospital-related factors made the largest contribution to variation (47%). CONCLUSION: Inpatient rehabilitation after TKR has increased in private health care during the past 8 years. Substantial variation in inpatient rehabilitation rates is not explained by patient-related factors, suggesting that some inpatient rehabilitation is low value care.

Care of patients with a diagnosis of chronic obstructive pulmonary disease: a cluster randomised controlled trial.

OBJECTIVE: To evaluate a partnership model of care for patients with a diagnosis of chronic obstructive pulmonary disease (COPD). DESIGN, SETTING AND PARTICIPANTS: Cluster randomised controlled trial with blinded outcome assessment of 44 general practices in south-western Sydney comprising 451 people with a diagnosis of COPD, conducted between 2006 and 2009. INTERVENTION: Participants from intervention group practices were visited at their home by a registered nurse with specific training in COPD care who worked with the general practitioner, the patient and other health professionals to develop and implement an individualised care plan based on best-practice guidelines. Participants from control group practices received usual care. MAIN OUTCOME MEASURES: The primary outcome was disease-related quality of life measured using the St George's Respiratory Questionnaire (SGRQ) at 12-month follow-up. Other outcomes were overall quality of life, lung function, smoking status, immunisation status, patient knowledge of COPD, and health service use. RESULTS: Of the 451 participants, 257 (57.8%) were confirmed as having COPD on post-bronchodilator spirometry. Follow-up was completed for 330 patients (73.2%). At 12 months, there was no statistically significant difference in the mean SGRQ scores between intervention and control groups (38.7 v 37.6; difference, 1.1; 95% CI, - 1.53-3.74; P = 0.41) or in measures of quality of life, lung function and smoking status. Compared with the control group, in the intervention group, attendance at pulmonary rehabilitation was more frequent (31.1% v 9.6%; OR, 5.16; 95% CI, 2.40-11.10; P = 0.002) and the mean COPD knowledge score was higher (10.5 v 9.8; difference, 0.70; CI, 0.10-1.21; P = 0.02). CONCLUSION: The nurse-GP partnership intervention did not have an impact on disease-related quality of life at 12-month follow-up. However, there was evidence of improved quality of care, in particular, in attendance at pulmonary rehabilitation and patient knowledge of COPD. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN012606000304538.

Assessment of MRI issues for a 3-T "immune" programmable CSF shunt valve.

OBJECTIVE: A newly developed CSF shunt valve that incorporates a magnetically adjustable mechanism designed to resist unintended setting changes was evaluated for problems during 3-T MRI. MATERIALS AND METHODS: Standardized protocols were used to assess magnetic field interactions, MRI-related heating, artifacts, and functional changes related to multiple exposures and various MRI conditions in nine different samples at 3 T. RESULTS: The magnetic field interactions were not excessive. MRI-related heating, which was studied at a relatively high, MRI system-reported whole body-averaged specific absorption rate (2.9 W/kg), was at a level that should not pose a hazard to a patient. Although artifacts were large in relation to the dimensions of this programmable CSF shunt valve, the results were consistent with similar devices containing permanent magnets. Multiple exposures and various MRI conditions at 3 T did not damage or affect the functional aspects of the devices, and no unintentional changes to the valve setting were observed. CONCLUSION: In consideration of the test results, this new programmable CSF shunt valve is not adversely affected by the 3-T MRI environment and is acceptable for a patient undergoing MRI at 3 T or less when specific guidelines are followed, including verifying the valve setting according to manufacturer recommendations immediately after the MRI procedure.

Predictors of accuracy of diagnosis of chronic obstructive pulmonary disease in general practice.

OBJECTIVES: To compare the clinical diagnosis of chronic obstructive pulmonary disease (COPD) with results of post-bronchodilator spirometry in general practice, and examine practitioner, practice and patient characteristics associated with agreement between clinical and spirometric diagnoses. DESIGN, SETTING AND PARTICIPANTS: General practitioners from practices in Sydney identified eligible patients aged 40-80 years seen in the past year and prescribed respiratory medications whom they regarded as having COPD. Between November 2006 and April 2008, we collected information on the GPs and their practices, and demographic information, smoking status, comorbidities, respiratory medicines use, vaccination status, quality of life and spirometry results for participating patients. MAIN OUTCOME MEASURES: Frequency of COPD diagnosis on spirometry; odds ratios for characteristics associated with agreement between clinical and spirometric diagnoses. RESULTS: 56 GPs from 44 practices participated in the study. Of 1144 eligible patients, 445 were recruited (mean age, 65 years; 49% male). Of these, 257 (57.8%) had post-bronchodilator spirometry consistent with COPD ± asthma, 16 (3.6%) had asthma only, 82 (18.4%) had normal spirometry, and 90 (20.2%) had other spirometric diagnoses. Having a spirometer in the practice was not predictive of agreement between clinical and spirometric diagnoses. Older patient age was significantly associated with correct diagnosis, while higher numbers of comorbidities were associated with misdiagnosis. CONCLUSIONS: A substantial proportion of patients clinically identified as having COPD in general practice do not have the condition according to spirometric criteria, with inaccurate diagnosis more common in patients with comorbidities. Policy and practice change is needed to support the use of spirometry in primary care.

A 'snap shot' of the health of homeless people in inner Sydney: St Vincent's Hospital.

OBJECTIVES: The poor health profile of people who are homeless results in a disproportionate use of health resources by these people. An in-hospital count of demographic and health data of homeless patients was conducted on two occasions at St Vincent's Hospital in Sydney as an indicator of health resource utilisation for the Sydney region. METHODS: Two in-hospital counts were conducted of homeless patients within the boundaries of St Vincent's Hospital to coincide with the inaugural City of Sydney homeless street counts in winter 2008 and summer 2009. Data collected included level of homelessness, principal diagnosis, triage category, bed occupancy and linkages to services post hospital discharge. RESULTS: Homeless patients at St Vincent's utilised over four times the number of acute ward beds when compared with the state average. This corresponds to a high burden of mental health, substance use and physical health comorbidities in homeless people. There was high utilisation of mental health and drug and alcohol services by homeless people, and high levels of linkages with these services post-discharge. There were relatively low rates of linkage with general practitioner and ambulatory care services. CONCLUSION: Increasing knowledge of the health needs of the homeless community will assist in future planning and allocation of health services.

Magnetically programmable shunt valve: MRI at 3-Tesla.

A magnetically programmable cerebrospinal fluid (CSF) shunt valve (Codman Hakim Programmable Valve, Codman, a Johnson & Johnson Company, Raynham, MA) was assessed for magnetic field interactions, heating, artifacts and functional changes at 3-Tesla. The programmable valve showed minor magnetic field interactions and heating (+0.4 degrees C). Artifacts were relatively large in relation to the size and shape of this implant and, as such, may create a problem if the area of interest is in proximity to this implant. While multiple exposures and various magnetic resonance imaging (MRI) conditions at 3-Tesla changed the settings of some valves (i.e., reprogramming was needed), the function of the programmable valve was not permanently affected. Therefore, this magnetically programmable CSF shunt valve is acceptable for a patient undergoing MRI at 3-Tesla or less when specific safety guidelines are followed, including resetting the valve, as needed.

Costing the ambulatory episode: implications of total or partial substitution of hospital care.

The Macarthur Health Service introduced an innovative Acute Ambulatory Care Service (MACS) in 2000. The service was designed to substitute patient care previously provided in hospital beds with care in the patient's home. The financial implications of complete or partial substitution of hospital care were explored using local data sources from the introduction of the service in 2001-2002. These data were analysed using the NSW Department of Health cost of care methodology. This study determined that episodes of care in MACS were less costly than equivalent episodes of inpatient care for selected diagnoses. The Macarthur cost of care data confirmed substantial savings (63%) in cases in certain diagnostic groups (cellulitis, pneumonia) with complete substitution, and lower savings (50%) for partial substitution of care when compared with hospital admission. Savings are likely to be greater as the level of substitution increases and are dependent on the choice of ambulatory sensitive diagnoses.

Outcomes of motor vehicle crashes with fracture: a pilot study of early rehabilitation interventions.

AIM: To determine the effects of early rehabilitation interventions on the physical, psychological and vocational outcomes of patients presenting to the Emergency Department with fracture resulting from a motor vehicle crash. METHOD: Prospective non-randomized cohort controlled trial. Seventy-six subjects were enrolled and formed 2 groups. The control group received usual care, and the intervention group received a consultation with a rehabilitation physician and was offered pain management, physiotherapy, psychological treatment and further specialist referrals if indicated. The battery of outcome measures covering pain, psychological assessment, return to work and return to driving was performed at the same time intervals for both cohorts. RESULTS: Significant (p < 0.05) improvement was seen in pain levels at 12 weeks in the intervention group compared to control group. The intervention group showed a significantly better rate of return to normal work compared to the control group. CONCLUSIONS: Early proactive rehabilitation can benefit patients with fractures resulting from motor vehicle crashes. This pilot study suggests the need for further investigation of the recovery from fractures among such patients.