Unmet healthcare needs, access to services and experiences with health providers among persons with spinal cord injury in Australia.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: Appropriate and timely lifelong access to healthcare following a spinal cord injury (SCI) is critical, yet unmet healthcare needs in this population are common. Poor experiences with healthcare providers can be a barrier to health-seeking behaviour, and we hypothesised that there would be an association between unmet healthcare needs and care experiences. This study aimed to: (1) describe healthcare provider utilisation in the past year, unmet care needs and satisfaction with healthcare services; (2) explore the association between experiences with healthcare providers and unmet healthcare needs; and (3) explore the association between healthcare provider utilisation and participant characteristics, including unmet healthcare needs. SETTING: Community. METHODS: Analysis of data for 1579 Australians aged ≥ 18, who were ≥ 1-year post-SCI and living in the community. Bayesian penalised regression was used to model six binary outcomes: unmet healthcare needs; the use of general practitioners (GPs), allied health practitioners, rehabilitation specialists; medical specialists; and hospitalisations in the past 12-months. RESULTS: Unmet needs were reported by 17% of participants, with service cost the common deterrent. There was evidence of an effect for provider experiences on unmet healthcare needs, but no evidence that unmet healthcare needs was associated with the use of GPs, allied health practitioners, and rehabilitation or medical specialists. CONCLUSIONS: Unmet healthcare needs were reported in the context of high healthcare use and large proportions of secondary conditions in a cohort with long-term SCI. Improved health access for people with SCI include better primary-secondary care collaboration is needed.

Meta-analysis prediction intervals are under reported in sport and exercise medicine.

AIM: Prediction intervals are a useful measure of uncertainty for meta-analyses that capture the likely effect size of a new (similar) study based on the included studies. In comparison, confidence intervals reflect the uncertainty around the point estimate but provide an incomplete summary of the underlying heterogeneity in the meta-analysis. This study aimed to estimate (i) the proportion of meta-analysis studies that report a prediction interval in sports medicine; and (ii) the proportion of studies with a discrepancy between the reported confidence interval and a calculated prediction interval. METHODS: We screened, at random, 1500 meta-analysis studies published between 2012 and 2022 in highly ranked sports medicine and medical journals. Articles that used a random effect meta-analysis model were included in the study. We randomly selected one meta-analysis from each article to extract data from, which included the number of estimates, the pooled effect, and the confidence and prediction interval. RESULTS: Of the 1500 articles screened, 866 (514 from sports medicine) used a random effect model. The probability of a prediction interval being reported in sports medicine was 1.7% (95% CI = 0.9%, 3.3%). In medicine the probability was 3.9% (95% CI = 2.4%, 6.6%). A prediction interval was able to be calculated for 220 sports medicine studies. For 60% of these studies, there was a discrepancy in study findings between the reported confidence interval and the calculated prediction interval. Prediction intervals were 3.4 times wider than confidence intervals. CONCLUSION: Very few meta-analyses report prediction intervals and hence are prone to missing the impact of between-study heterogeneity on the overall conclusions. The widespread misinterpretation of random effect meta-analyses could mean that potentially harmful treatments, or those lacking a sufficient evidence base, are being used in practice. Authors, reviewers, and editors should be aware of the importance of prediction intervals.

Prevalence of opioid use in adults with spinal cord injury: A systematic review and meta-analysis.

OBJECTIVE: To determine the prevalence, reported harms and factors associated with opioid use among adults with spinal cord injury (SCI) living in the community. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Comprehensive literature searches were conducted in PubMed (MEDLINE), EMBASE, CINAHL, Web of Science and Scopus for articles published between 2000 and 2023. Risk of bias was assessed using a prevalence-specific tool. Random-effects meta-analyses were conducted to pool prevalence data for any context of opioids. Sensitivity and subgroup analyses were also performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study protocol was registered via Prospero (CRD42022350768). RESULTS: Of the 4969 potential studies, 38 were included in the review. Fifty-three percent of studies had a low risk of bias, with a high risk of bias in 5% of studies. The pooled prevalence for the 38 studies included in the meta-analysis (total cohort size of 50,473) across any opioid context was 39% (95% confidence interval [CI], 32-47). High heterogeneity was evident, with a prediction interval twice as wide as the 95% CI (prediction interval, 7-84%). Mean or median opioid dose was unreported in 95% of studies. Opioid dose and factors related to opioids were also rarely explored in the SCI populations. CONCLUSIONS: Results should be interpreted with caution based on the high heterogeneity and imprecise pooled prevalence of opioids. Contextual details including pain, cohort-specific injury characteristics and opioid dosage were inconsistently reported, indicating a clear need for additional studies in a population at greater risk of experiencing opioid-related adverse effects.

Use and cost of Medicare Benefits Schedule and Pharmaceutical Benefits Scheme services following inpatient rehabilitation for acquired disability in Australia.

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.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) community survey: 1. population-based design, methodology and cohort profile.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To describe design and methods of Australian arm of International Spinal Cord Injury (Aus-InSCI) community survey, reporting on participation rates, potential non-response bias and cohort characteristics. SETTING: Survey of community-dwelling people with SCI at least 12 months post-injury, recruited between March 2018 and January 2019, from state-wide SCI services, a government insurance agency and not-for-profit consumer organisations across four Australian states. METHODS: The Aus-InSCI survey combined data for people with SCI from nine custodians, using secure data-linkage processes, to create a population-based, anonymised dataset. The Aus-InSCI questionnaire comprised 193 questions. Eligibility, response status and participation rates were calculated. Descriptive statistics depict participant characteristics. Logistic regression models were developed for probability of participation, and inverse probability weights generated to assess potential non-response bias. RESULTS: 1579 adults with SCI were recruited, a cooperation rate of 29.4%. Participants were predominantly male (73%), with 50% married. Mean age was 57 years (range 19-94) and average time post-injury 17 years (range 1-73). Paraplegia (61%) and incomplete lesions (68%) were most common. Males were more likely than females to have traumatic injuries (p < 0.0001) and complete lesions (p = 0.0002), and younger age-groups were more likely to have traumatic injuries and tetraplegia (p < 0.0001). Potential non-response bias evaluated using selected outcomes was found to be negligible in the Aus-InSCI cohort. CONCLUSIONS: The Aus-InSCI survey made efforts to maximise coverage, avoid recruitment bias and address non-response bias. The distributed, linked and coded (re-identifiable at each custodian level) 'virtual quasi-registry' data model supports systematic cross-sectional and longitudinal research.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey: 2. Understanding the lived experience in people with spinal cord injury.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To identify common problems across key domains of functioning, health and wellbeing, as well as evaluate self-reported quality of life (QoL) by people with SCI, examining differences by age, gender, injury characteristics and level of mobility. SETTING: Data from four state-wide SCI clinical services, one government insurance agency and three not-for-profit consumer organisations. METHODS: Participants were 18 years or over with SCI and at least 12 months post-injury, recruited between Mar'18 and Jan'19. The Aus-InSCI questionnaire comprised 193 questions, including socio-demographics, SCI characteristics, body functions and structures, activities and participation, environmental and personal factors, and appraisal of health and well-being. General linear model was used to examine differences in functioning and QoL. RESULTS: Participants (mean age 57 years, range 19-94 years) with tetraplegia and/or complete injuries had more health problems, activity/participation problems and environmental barriers. However, self-rated overall QoL did not differ for injury level or completeness. Participants with more recent injuries exhibited lower independence levels, more mental health problems and poorer satisfaction with self and their living conditions. Major activity/participation problems related to intimate relationships and accessing public transportation. Less than half of the working age population were engaged in paid work. The top two environmental barriers frequently related to accessing public places or homes and unfavourable climatic conditions. CONCLUSIONS: This large, comprehensive community survey draws a detailed picture of the lived experience of people with SCI in Australia, identifying priority needs, gaps in services and barriers to achieving a full and satisfying life.

Factors Related to Engagement in Employment After Spinal Cord Injury in Australia: A Cross-sectional Study.

OBJECTIVE: To explore the association between sociodemographic, health, functional independence, and environmental variables with engagement in paid work for people with spinal cord injury (SCI). DESIGN: Self-reported, cross-sectional Australian data from a large international SCI survey. SETTING: Community-based. PARTICIPANTS: 1189 working-age people with SCI (18-67 years) or aged >67 years and engaged in paid employment. Respondents were community based and at least 1 year after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment and work integration variables. Bayesian penalized regression was used to determine associations between 23 predictor variables and engagement in paid work. RESULTS: Most participants (87%) were employed pre-injury, with 39% in paid employment at the time of the survey. Participants who attained a master's/doctoral degree (odds ratio [OR]=3.01; 95% credible interval [CrI], 1.63, 5.44) and those married (OR=1.68; 95% CrI, 1.13, 2.49) were more likely to be engaged in paid work. Women (OR=0.55; 95% CrI, 0.37, 0.81), people receiving a disability pension (OR=0.17; 95% CrI, 0.13, 0.24), and older participants (OR=0.75; 95% CrI, 0.63, 0.90) were less likely to be in paid work. Working participants identified hardships including problems completing their work (60%) and accessing the workplace (32%), as well as unmet needs relating to assistive devices required for completing their work (50%). CONCLUSIONS: Findings from the current study can assist in directing resources to subgroups within the SCI population who need greater assistance or intervention related to employment outcomes, including through vocational rehabilitation services/programs. Unmet needs and workplace issues expressed by employed individuals identify gaps in work integration and satisfaction that could affect employment sustainability that need to be addressed.

Feasibility of an asynchronous general practitioner-to-general physician eConsultant outpatient substitution program: A Queensland pilot study.

BACKGROUND AND OBJECTIVES: The use of an 'eConsultant' to support the family physician is an established outpatient substitution model in North America. This pilot study investigates the feasibility of the eConsultant model for complex chronic disease management within the Australian setting. METHOD: This pilot study was implemented in one urban and four rural/remote general practices in one state. The general practitioner (GP) sent a request for advice (RFA), a clinical summary with a specific clinical question/s, via secure messaging to a physician working remotely. Responses were required for GP/patient follow-up within 72 hours. RESULTS: The mean (standard deviation [SD]) time for general physician reply was 2.1 (1.2) days, and mean (SD) time from initial to subsequent GP/patient review was 14.8 (16.7) days. Only 13.3% of eConsultations required a subsequent face-to-face outpatient department appointment. DISCUSSION: The eConsultant model is feasible in Australia, with potential for improving access and reducing time to non-GP specialist input.

Employment outcomes following spinal cord injury: a population-based cross-sectional study in Australia.

STUDY DESIGN: Self-reported cross-sectional data for the Australian cohort participating in the International Spinal Cord Injury Community survey. OBJECTIVES: To contextualise post-injury employment for people with spinal cord injury (SCI) in Australia, including work participation rates, time to resuming work, underemployment and pre- and post-SCI employment changes. SETTING: Australian survey data from four state-wide SCI services, one government insurance agency and three not-for-profit consumer organisations across New South Wales, Queensland, South Australia and Victoria. METHODS: Data were analysed from 1579 participants with SCI who are at least 1-year post discharge from an inpatient facility. Survey measures included 16-items dedicated to employment. Pre- and post-injury job titles were based on the International Standard Classification of Occupations (ISCO-08) major classification. A mix of chi-squared, t-test and negative binomial regression were used to analyse data. RESULTS: The absolute post-injury employment rate was 49.9%, with one-third of the sample currently working. Pre-injury employment and engagement with vocational rehabilitation resulted in higher employment rates. Individuals who were unable to return immediately following inpatient rehabilitation took mean 28 months (SD, 35.9) to return. Time to employment was significantly lengthier for those without pre-injury jobs, at 59.7 months [SD, 43.8] (p < 0.001). Engagement in less manual roles increased post-injury, accounting for three quarters of post-SCI jobs. Underemployment was identified by 16.6% of those currently working. CONCLUSIONS: While there are current services and programmes in place in Australia that support post-injury employment, findings indicate a need for more comprehensive early intervention focused services targeted towards employers and individuals.

Improving quality in general practice using the Primary Care Practice Improvement Tool (PC-PIT) with Primary Health Network support.

Optimal primary care sector performance is vital for ensuring the delivery of quality health services and effective clinical management of populations. The Primary Care Practice Improvement Tool (PC-PIT) incorporates subjective staff input and objective indicators to measure 13 elements of organisational performance. This study aimed to measure change in organisational performance for general practices using the PC-PIT with Primary Health Network (PHN) support. A pre-post design was used for changes in PC-PIT subjective and objective scores. Practices used results with PHN support to complete two Plan Do Study Act initiatives and were reassessed 9-months later. PC-PIT scales were dichotomised into lower and higher scores, with odds ratios used to determine effect size. Staff survey response rates were 55.4% at baseline and 50.1% at follow up. There were modest increases in the likelihood of staff rating several elements higher at follow up. When implemented with PHN support staff, the PC-PIT has the potential for effective, focussed and sustained quality improvement, with capacity to support Health Care Home model transition and implementation.

The availability of task-specific feedback does not affect 20 km time trial cycling performance or test-retest reliability in trained cyclists.

OBJECTIVES: This study examined the influence of the availability of task-specific feedback on 20 km time trial (20TT) cycling performance and test-retest reliability. DESIGN: Thirty trained, club-level cyclists completed two 20TT's on different days, with (feedback, FB) or without (no-feedback, NFB) task-specific feedback (i.e., power output, cadence, gear and heart rate [HR]). Elapsed distance was provided in both conditions. METHODS: During trials, ergometer variables and HR were continuously recorded, and a rating of perceived exertion (RPE) was collected every 2 km. Data were analysed using linear mixed-effects models in a Bayesian framework, and Cohen's d was calculated for standardised differences. The reliability of finish time and mean power output (PO) was determined via multiple indices, including intraclass correlations (ICC). RESULTS: Performance, pacing behaviour, and RPE were not statistically different between conditions. The posterior mean difference [95% credible interval] between TT1 and TT2 for FB and NFB was 10s [-5, 25] and -2s [-17, 14], respectively. In TT2, HR was statistically higher (∼8bmin-1) in FB compared to NFB after 13 km (d = 2.08-2.25). However, this result was explained by differences in maximal HR. Finish time (FB: ICC= 0.99; NFB: ICC=0.99) and mean power output (FB: ICC=0.99; NFB: ICC=0.99) in each condition were substantially reliable. CONCLUSIONS: The availability of task-specific information did not affect 20TT performance or reliability. Except for elapsed distance, task-specific feedback should be withheld from trained cyclists when evaluating interventions that may affect performance, to prevent participants from recalling previous performance settings.

The Primary Care Practice Improvement Tool (PC-PIT) process for organisational improvement in primary care: application by Australian Primary Health Networks.

The Primary Care Practice Improvement Tool (PC-PIT) is an organisational performance improvement tool recently implemented by two Primary Health Networks (PHNs). This study explored barriers and facilitators to implementing the PC-PIT process at scale, from the initial introduction of the tool to completion of Plan-Do-Study-Act cycles with general practices. Using a qualitative design, in-depth, semi-structured interviews were conducted with 10 PHN staff to seek feedback on the delivery of the PC-PIT to general practices. Interview results were analysed using a grounded theory approach. The identification of barriers such as difficulty engaging practices and lack of report sharing with the PHNs will help streamline future implementation. The PC-PIT was highly compatible with existing quality improvement programs and offers enhanced opportunity to support capacity building and implementation of the Health Care Home model.

Clinical outcomes of an integrated primary-secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial.

AIMS/HYPOTHESIS: The aim of the study was to determine if a Beacon model of integrated care utilising general practitioners (GPs) with special interests could achieve similar clinical outcomes to a hospital-based specialist diabetes outpatient clinic. METHODS: This pragmatic non-inferiority multisite randomised controlled trial assigned individuals with complex type 2 diabetes to care delivered by a Beacon clinic or to usual care delivered by a hospital outpatient department, in a 3:1 ratio. Owing to the nature of the study, researchers were only blinded during the allocation process. Eligible participants were aged 18 or over, had been referred by their usual GP to the hospital central referral hub with type 2 diabetes and had been triaged to be seen within 30 or 90 days. The intervention consisted of diabetes management in primary care by GPs with a special interest who had been upskilled in complex diabetes under the supervision of an endocrinologist. The primary outcome was HbA1c at 12 months post-recruitment. The non-inferiority margin was 4.4 mmol/mol (0.4%). Both per-protocol and intention-to-treat analyses are reported. RESULTS: Between 27 November 2012 and 14 July 2015, 352 individuals were recruited and 305 comprised the intention-to-treat sample (71 in usual care group and 234 in the Beacon model group). The Beacon model was non-inferior to usual care for both the per-protocol (difference -0.38 mmol/mol [95% CI -4.72, 3.96]; -0.03% [95% CI -0.43, 0.36]) and the intention-to-treat (difference -1.28 mmol/mol [95% CI -5.96, 3.40]; -0.12% [95% CI -0.55, 0.31]) analyses. Non-inferiority was sustained in a sensitivity analysis at 12 months. There were no statistically or clinically significant differences in the secondary outcomes of BP, lipids or quality of life as measured by the 12 item short-form health survey (SF-12v2) and the diabetes-related quality of life (DQoL-Brief) survey. Safety indicators did not differ between groups. Participant satisfaction on the eight-item client satisfaction questionnaire (CSQ-8) was good in both groups, but scores were significantly higher in the Beacon model group than the usual care group (mean [SD] 28.4 [4.9] vs 25.6 [4.9], respectively, p < 0.001). CONCLUSIONS/INTERPRETATION: In individuals with type 2 diabetes, a model of integrated care delivered in the community by GPs with a special interest can safely achieve clinical outcomes that are not inferior to those achieved with gold-standard hospital-based specialist outpatient clinics. Individuals receiving care in the community had greater satisfaction. Further studies will determine the cost of delivering this model of care. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612000380897 FUNDING: The study was funded by the Australian National Health and Medical Research Council (GNT1001157).