Potential role of general practice in reducing emergency department demand: A qualitative study.

OBJECTIVE: To inform local, state and national strategies intended to reduce demand for ED care, the present study aimed to identify key factors influencing the current provision of acute care within primary healthcare (PHC) and explore the policy and system changes potentially required. METHODS: Semi-structured interviews with key stakeholders were audio-recorded, transcribed verbatim and analysed through content and thematic approaches incorporating the Walt and Gilson health policy framework. RESULTS: Eleven interviews were conducted. Five key considerations were highlighted, namely the barriers and enablers for general practitioners (GPs) in providing acute care, barriers to patient use of PHC instead of ED, suggestions for new PHC models and improvements for current ED models. Additionally, economic issues relating to clinic funding and GP remuneration, complexities of state or federal funding and management of urgent care centres (UCC) were identified. Potential policy changes included GP clinics incorporating emergency appointments, GP triage, further patient streaming and changes to the ED medical workforce model, as well as linking hospitals with PHC clinics. Suggested system changes included improving rapid access to non-GP specialists, offering qualifications for urgent care within PHC, developing integrated information technology systems and educating patients regarding appropriate healthcare system pathways. CONCLUSION: The present study suggested that while PHC has the potential to attenuate the demands for ED services, a whole-of-system approach focusing on realignment of priorities and integrated changes are needed.

Acceptability of emergency department triage nurse's advice for patients to attend general practice: A cross-sectional survey.

OBJECTIVES: Demand for ED care is increasing at a rate higher than population growth. Strategies to attenuate ED demands include diverting low-acuity general practice-type ED attendees to alternate primary healthcare settings. The present study assessed the ED attendees' receptiveness to accept triage nurse's face-to-face advice to explore alternate options for medical care and what factors influence the level of acceptance. METHODS: The ED attendees of four major public hospital EDs in Brisbane were surveyed between August and October 2018, using a questionnaire informed by Health Belief Model's cues to action. RESULTS: Of the 514 valid responses, 81% of respondents were very likely/likely to accept the triage nurse's advice to see a general practitioner. Self-perceived urgency of presenting condition/s (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78-0.97), not having confidence in general practitioner (OR 0.37, 95% CI 0.21-0.66) and having a medical record at the hospital (OR 0.60, 95% CI 0.36-0.99) were negatively associated with the likelihood of accepting the advice. For every point increase in perceived seriousness, the odds of accepting the advice decreased by 16% (95% CI 6-25%). CONCLUSION: Most of the participants believed that EDs were for emergent care and they attended the ED because they perceived their presenting condition/s to be serious and/or urgent. The acceptability of face-to-face advice by triage nurse to seek help in general practice was influenced by perceived threats of the illness, and the underlying beliefs about availability, accessibility, suitability and affordability of the service.

The public health care system and primary care services in Saudi Arabia: a system in transition.

BACKGROUND: Saudi Arabia has invested heavily in its health care system by establishing health care infrastructures to improve health of the nation. However, it remains to be seen whether it is efficient and effective in providing health care services needed. Primary health care, which is the basis of universal health coverage, needs to be assessed on its performance, challenges and future opportunities to serve the Saudi Arabian population. AIMS: This review aimed to identify challenges within the Saudi Arabian health care system with a focus on primary health care services, and to analyse the interrelated factors in order to suggest remedial reforms to further strengthen and improve the health care system. METHODS: A narrative review of previous studies and governmental reports was undertaken to extract, analyse, synthesize and report the findings. RESULTS: The review found a number of key areas for improvement in the primary health care system. These areas include: the scope, structure, infrastructure, financing, increased demand, increased costs and workforce capacity. Other critical challenges include inequitable access to health services, quality and safety of services, the growing burden of chronic diseases, lack of an effective information system, management and leadership issues, and gaps in the referral system. CONCLUSION: The Saudi Arabian health care system needs comprehensive reform with a focus on primary health care.

General practitioner-type patients in emergency departments in metro North Brisbane, Queensland: A multisite study.

OBJECTIVE: To estimate the proportion of ED patients in urban Queensland who are potentially suitable for general practitioner (GP) care. METHODS: A retrospective analysis was conducted using ED Information System data from Metro North Hospital and Health Service in Brisbane, Australia for three consecutive financial years (2014-2015 to 2016-2017). The hospitals included two Principal Referral and two Public Acute hospitals. GP-type patients were calculated using the Australian Institute of Health and Welfare (AIHW), Australasian College for Emergency Medicine (ACEM) and the validated Sprivulis methods. RESULTS: Of the 822 841 ED presentations, 219 567 (27%) were potentially GP-type patients by AIHW, 49 307 (6%) by ACEM and 61 836 (8%) by Sprivulis methods. The higher proportion of GP-type presentations were during 08.00 to 17.00 hours by AIHW and ACEM methods. Of the lower-acuity triage categories of 4 (286 154 presentations) and 5 (5658 presentations), AIHW estimated that 62% and 80% of the patients were GP-type patients, as compared to 9% and 22% by ACEM, and 9% and 0.3% by Sprivulis method. The mean costs of adult GP-type patients is $345 by the AIHW and $406 by the ACEM method, lower than non-GP type patients ($706 and $622, respectively). CONCLUSIONS: There is considerable variation in what is considered GP-type ED presentations based on the three methods employed and this variation may have fuelled the debate surrounding what is 'avoidable' ED utilisation. Regardless, the study findings provide an interesting addition to defining and addressing appropriate utilisation of ED services.

Review article: Interventions for people presenting to emergency departments with a mental health problem: A systematic scoping review.

The number of people presenting to EDs with mental health problems is increasing. To enhance and promote the delivery of safe and efficient healthcare to this group, there is a need to identify evidence-based, best-practice models of care. This scoping review aims to identify and evaluate current research on interventions commenced or delivered in the ED for people presenting with a mental health problem. A systematic search of eight databases using search terms including emergency department, mental health, psyc* and interventions, with additional reference chaining, was undertaken. For included studies, level of evidence was assessed using the NHMRC research guidelines and existing knowledge was synthesised to map key concepts and identify current research gaps. A total of 277 papers met the inclusion criteria. These were grouped thematically into seven domains based on primary intervention type: pharmacological (n = 43), psychological/behavioural (n = 25), triage/assessment/screening (n = 28), educational/informational (n = 12), case management (n = 28), referral/follow up (n = 36) and mixed interventions (n = 105). There was large heterogeneity observed as to the level of evidence within each intervention group. The interventions varied widely from pharmacological to behavioural. Interventions were focused on either staff, patient or institutional process domains. Few interventions focused on multiple domains (n = 64) and/or included the patient's family (n = 1). The effectiveness of interventions varied. There is considerable, yet disconnected, evidence around ED interventions to support people with mental health problems. A lack of integrated, multifaceted, person-centred interventions is an important barrier to providing effective care for this vulnerable population who present to the ED.

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective.

BACKGROUND: The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project. METHODS: The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015-2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis. RESULTS: Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels. CONCLUSION: Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff's experiences.

Factors affecting the performance of public out-patient services.

Objective The delivery of public out-patient services is an essential part of complex healthcare systems, but the contribution of public out-patient services is often ill defined and poorly evaluated. The aim of this study was to identify and better understand those factors that may affect the performance of out-patient services to provide health service managers, clinicians and executives with a conceptual framework for future decision-making processes. Methods The present qualitative research involved five exploratory case studies. These case studies were conducted across two specialties at hospitals in the Metro North Hospital and Health Service in Queensland. Data were obtained from 38 interviews and 15 focus groups, and were analysed to identify common themes. Further analysis helped identify the most significant factors and build a conceptual framework for understanding the relationships between those factors and their effect on performance. Results Across both specialties there were 10 factors (scheduling, performance, service framework, categorisation or prioritisation of patients, internal and external stakeholders, resources, service demand, culture, system challenges and medical stakeholders) identified that may affect the performance of out-patient services. These factors were condensed into five core domains: culture, stakeholders, resources, demand and system reform. Conclusion Strategies to address the five core domains identified may provide a framework for sustainable improvement in the delivery of out-patient services. What is known about the topic? The provision of specialist out-patient services is an essential element of health service delivery. Access to specialist services in the public sector is challenging because of the escalating demand associated with an increasing and aging demographic. The factors that may affect the delivery of out-patient services need to be addressed for long-term sustainable improvement. What does this paper add? This paper provides a conceptual framework grounded in rigorous qualitative data analysis for understanding the internal and external factors that affect waiting times for specialist out-patient services. The results of this qualitative research indicate that there are five core domains that may influence waiting times in the public out-patient setting. When these domains are addressed at the strategic, tactical and operational levels, they have the potential to provide significant improvement in the delivery of out-patient services. What are the implications for practitioners? This paper guides the attention of relevant stakeholders towards the five core domains identified (culture, stakeholders, resources, demand and system reform) that influence the performance of waiting times at the operational, tactical and strategic levels within the public hospital setting.

Emergency department models of care in Queensland: a multisite cross-sectional study.

Objective The acuity and number of presentations being made to emergency departments (EDs) is increasing. In an effort to safely and efficiently manage this increase and optimise patient outcomes, innovative models of care (MOC) have been implemented. What is not clear is how these MOC reflect the needs of patients or relate to each other or to ED performance. The aim of this study was to describe ED MOC in Queensland, Australia. Methods Situated within a larger mixed-methods study, the present study was a cross-sectional study. In early 2015, leaders (medical directors and nurse managers) from public hospital EDs in Queensland were invited to complete a survey detailing ED activity, staffing profiles, treatment space, MOC and National Emergency Access Target (NEAT) performance. Routinely collected ED information system data was also used. Results Twenty of the 27 EDs invited participated in the study (response rate 74%). An extensive array of MOC were identified that were categorised into those that facilitate input, throughput and output from the ED. There was no consistent evidence as to the relative effectiveness of these MOC in achieving ED performance benchmarks, such as NEAT performance. Conclusion There is considerable variability in the MOC used throughout EDs in Queensland. A more complete analysis of the relative effectiveness of different MOC either in isolation or as part of a comprehensive approach would help inform more consistent MOC in Queensland EDs. What is known about the topic? MOC in any given ED are implemented in response to factors such as the geographical location of the hospital, hospital-specific characteristics and service profile, staffing profile and patient demographic profile. In the era of time-based targets, they may also serve to address a particular aspect of flow in the face of rising ED demand. Although many of the MOC attempt to deal with flow in a linear fashion, target specific phases of the ED journey or address particular patient cohorts, what is clear is that not all EDs are shaped and formed the same. What does this paper add? The study provides a comprehensive description of the varied models of care operating within Queensland public hospital EDs and how they relate to ED performance. A basic taxonomy of contemporary ED MOC is necessary to allow comparison between departments and inform decisions regarding safety, efficiency and cost-effectiveness. What are the implications to practitioners? A contemporary understanding of the presence and profile of ED MOC that currently exist within a network of hospitals and health services is important for managers, clinicians and patients to inform decision-making regarding the safety, clinical effectiveness and cost-effectiveness of these models. This understanding can also inform where and how further improvements in care delivery can progress.

Impact of the National Emergency Access Target policy on emergency departments' performance: A time-trend analysis for New South Wales, Australian Capital Territory and Queensland.

OBJECTIVE: To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance. METHODS: A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi-level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short-stay admission (≤24 h), >24 h admissions, unplanned ED re-attendances within 7 days and 'left at own risk' (including 'did not wait for assessment'). RESULTS: Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short-stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED re-attendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67). CONCLUSION: ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time-based measures. Significant increases in short-stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re-attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.

Impact of the four-hour National Emergency Access Target on 30 day mortality, access block and chronic emergency department overcrowding in Australian emergency departments.

OBJECTIVE: Previous research reported strong associations between ED overcrowding and mortality. We assessed the effect of the Four-Hour Rule (4HR) intervention (Western Australia (WA) 2009), then nationally rolled out as the National Emergency Access Target (Australia 2012) policy on mortality and patient flow. METHODS: A longitudinal cohort study of a population-wide 4HR, for 16 hospitals across WA, New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD). Mortality trends were analysed for 2-4 years before and after 4HR using interrupted time series technique. Main outcomes included the effect of 4HR on patient flow markers; admitted 30 day mortality trends; and patient flow marker performance during the study period. RESULTS: There were 40 281 deaths from 952 726 emergency admissions. All jurisdictions, except ACT, had improved flow and access block after 4HR. Age-standardised mortality was decreasing before the intervention. Post-intervention, WA had a significant reduction in mortality rate of -0.28 per 1000 patients per quarter (P = 0.040) while QLD had mixed results and NSW/ACT trends did not change significantly. Meta-regression of aggregated data for hospitals grouped on flow performances did not show significant mortality changes associated with the policy. CONCLUSIONS: The 4HR was introduced as a means of driving hospital performance by applying a time target. Patient flow improved, but the evidence for mortality benefit is controversial with improvement only in WA. Further research with more representative data from a larger number of hospitals over a longer time across Australia is needed to increase statistical power to detect long-term effects of the policy.

Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine.

BACKGROUND: The main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments. METHODS: We used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015-2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study, RESULTS: We adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement. CONCLUSION: Based on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance; they will be reported separately.

Understanding ED performance after the implementation of activity-based funding.

OBJECTIVE: The aim of this study was to describe emergency department (ED) activities and staffing after the introduction of activity-based funding (ABF) to highlight the challenges of new funding arrangements and their implementation. METHODS: A retrospective study of public hospital EDs in Queensland, Australia, was undertaken for 2013-2014. The ED and hospital characteristics are described to evaluate the alignment between activity and resourcing levels and their impact on performance. RESULTS: Twenty EDs participated (74% response rate). Weighted activity units (WAUs) and nursing staff varied based on hospital type and size. Larger hospital EDs had on average 9076 WAUs and 13 full time equivalent (FTE) nursing staff per 1000 WAUs; smaller EDs had on average 4587 WAUs and 10.3 FTE nursing staff per 1000 WAUs. Medical staff was relatively consistent (8.1-8.7 FTE per 1000 WAUs). The proportion of patients admitted, discharged, or transferred within 4 hours ranged from 73% to 79%. The ED medical and nursing staffing numbers did not correlate with the 4-hour performance. CONCLUSION: Substantial variation exists across Queensland EDs when resourcing service delivery in an activity-based funding environment. Historical inequity persists in the staffing profiles for regional and outer metropolitan departments. The lack of association between resourcing and performance metrics provides opportunity for further investigation of efficient models of care.

Time to wait: a systematic review of strategies that affect out-patient waiting times.

Objective Out-patient waiting times pose a significant challenge for public patients in need of specialist evaluation and intervention. The aim of the present study was to identify and categorise effective strategies to reduce waiting times for specialist out-patient services with a focus on the Australian healthcare system. Methods A systematic review of major health databases was conducted using the key terms 'outpatient*' AND 'waiting time', 'process*' AND 'improvement in outpatient clinics'. Identified articles were assessed for their relevance by sequential review of the title, abstract and full text. References of the selected manuscripts were scanned for additional relevant articles. Selected articles were evaluated for consistent and emerging themes. Results In all, 152 articles were screened, of which 38 were included in the present review. Numerous strategies identified in the articles were consolidated into 26 consistent approaches. Three overarching themes were identified as significantly affecting waiting times: resource realignment, operational efficiency and process improvement. Conclusions Strategies to align resources, increase operational efficiency and improve processes provide a comprehensive approach that may reduce out-patient waiting times. What is known about the topic? Out-patient waiting times are a challenge in most countries that seek to provide universal access to health care for all citizens. Although there has been extensive research in this area, many patients still experience extensive delays accessing specialist care, particularly in the public health sector. The multiple factors that contribute to bottlenecks and inefficiencies in the referral process and affect patient waiting times are often poorly understood. What does this paper add? This paper reviews the published healthcare literature to identify strategies that affect specialist out-patient waiting times for patients. The findings suggest that there are numerous operational strategies that affect waiting times. These strategies may be categorised into three overarching themes (resource alignment, operational efficiencies and out-patient processes) that, when actioned in a coordinated approach, have the potential to significantly reduce out-patient waiting times. What are the implications for practitioners? This paper identifies evidence-based strategies for aligning resources, improving operational efficiency and streamlining processes, which may provide improvements to specialist out-patient waiting times for patients. Addressing the identified organisational, person-related, cultural and attitudinal factors will assist health system managers and health practitioners target the most appropriate improvement activities to reduce waiting times.

Uniting emergency and inpatient clinicians across the ED-inpatient interface: The last frontier?

Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED-inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system-wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes.

Patients' choice between public and private hospital emergency departments: a cross-sectional survey.

OBJECTIVE: The aim of this study was to understand what factors influence patients' choice between public and private hospital ED and the relative weight of those factors among adult patients with private health insurance in Australia. METHODS: A survey of 280 patients was conducted in four public and private hospitals' EDs in Brisbane between May and August 2015. The survey included information about respondent's demographics, nature of illness, decision-making, attitudes and choice. Independent t-test and Pearson's χ²-test were used to identify binary associations, and logistic regression was used to determine what factors influence patients' choice. RESULTS: Patients who agreed that 'long waiting time is a barrier to access public hospital ED' were twice as likely to choose private hospitals (odds ratio [OR] 2.172, P = 0.001). Alternatively patients who did not consider that 'there were long waiting times in public hospital ED' were less likely to access private hospitals (OR 0.200, P = 0.003). More public hospital patients (70.7%) than private hospital patients (56.4%) (P = 0.015) agreed that 'out-of-pocket payment is a barrier to accessing private hospital ED'. Patients attending private hospitals rated the quality of service higher than those attending public hospitals (OR 1.26, P = 0.001). CONCLUSION: Longer waiting times in public EDs is the principal issue considered by patients choosing private EDs and the out-of-pocket payment for accessing private EDs is the principal issue considered by public ED patients. The study suggests that addressing the out-of-pocket payments will attract more patients with private health insurance to access private EDs.

Agreement between triage category and patient's perception of priority in emergency departments.

BACKGROUND: Patients attending hospital emergency departments (ED) commonly cite the urgency and severity of their condition as the main reason for choosing the ED. However, the patients' perception of urgency and severity may be different to the nurses' perception of their urgency and severity, which is underpinned by their professional experience, knowledge, training and skills. This discordance may be a cause of patient dissatisfaction. The purpose of this study is to understand the extent of agreement/disagreement between the patient's perceived priority and actual triage category and associated factors. METHODS: A cross-sectional survey of 417 patients attending eight public hospital EDs in Queensland, Australia between March and May 2011 was conducted. The survey included patient's perceived priority and other health-related, socio-demographic and perceptual factors. Patients' triage category data were retrieved from their ED records and linked back to their survey data. Descriptive and multinomial logistic regression analyses were used. RESULTS: Over 48 % of the respondents expected to be given higher priority than the actual triage category they were assigned; 31 % had their perceived priority matched with the triage category; and 20 % of the respondents expected a lower priority than the triage category they received (Kappa 0.07, p < 0.01). Patients who expected a higher priority tended to be more frequent users (≥3 times in the past six months), and to score higher on perceived seriousness, perceived urgency, and pain score compared to the patients whose perceived priority matched the triage category or anticipated a lower priority. In the multivariate analysis, only perceived urgency remained significantly associated with expected higher priority (OR = 1.27, 95 % CI: 1.14-1.43). DISCUSSION: Our findings clearly confirmed the discrepancy between patient perception of urgency and staff assessment of urgency. This can have important implications particularly for the patients who underrate the urgency of their condition. Improved and open communication and the incorporation of the 'patient voice' into the triage process require understanding the patient's perspectives and their involvement in the decision making process. CONCLUSIONS: Noted differences between patient and practitioner perception of clinical urgency were identifed in this study.

Who benefited from the New Rural Cooperative Medical System in China? A case study on Anhui Province.

BACKGROUND: The goal of the New Rural Cooperative Medical System (NCMS) is to decrease the financial burden and improve the health of rural areas. The purpose of the present study is to determine how government subsidies vary between poorer and wealthier groups, especially in low-income regions in rural China. METHODS: The distribution, amount, and equity of government subsidies delivered via NCMS to rural residents at different economic levels were assessed using benefit-incidence analysis, concentration index, Kakwani index, Gini index, Lorenz curve, and concentration curve. Household and health institution surveys were conducted in 2010, covering 9701 residents. Household socio-economic status, healthcare costs, out-of-pocket payments, and utilization information were collected in household interviews, and reimbursement policy was provided by institutional survey. RESULTS: The government subsidy concentration index was -0.055 for outpatients and 0.505 for inpatients; and the outpatient and inpatient subsidy Kakwani indexes were -0.376 and 0.184, respectively. The poorest 20 % of populations received 3.4 % of the total subsidy output; while the wealthiest 20 % received 54.3 %. The results showed that the distribution of outpatient subsidies was equitable, but the hospital subsidies disproportionally benefited wealthier people. CONCLUSIONS: Wealthier people benefited more than poorer people from the NCMS in terms of inpatient and total subsidies. For outpatients, the subsidies were unrelated to ability to pay. This contradicts the common belief that the NCMS does not exacerbate benefit inequity. Long-term policy is required to tackle this problem, specifically of redesign the NCMS reimbursement system.

An Empirical Analysis of Rural-Urban Differences in Out-Of-Pocket Health Expenditures in a Low-Income Society of China.

OBJECTIVE: The paper examines whether out-of-pocket health care expenditure also has regional discrepancies, comparing to the equity between urban and rural areas, and across households. METHOD: Sampled data were derived from Urban Household Survey and Rural Household Survey data for 2011/2012 for Anhui Province, and 11049 households were included in this study. The study compared differences in out-of-pocket expenditure on health care between regions (urban vs. rural areas) and years (2011 vs. 2012) using two-sample t-test, and also investigated the degree of inequality using Lorenz and concentration curves. RESULT: Approximately 5% and 8% of total household consumption expenditure was spent on health care for urban and rural populations, respectively. In 2012, the wealthiest 20% of urban and rural population contributed 49.7% and 55.8% of urban and rural total health expenditure respectively, while the poorest 20% took only 4.7% and 4.4%. The concentration curve for out-of-pocket expenditure in 2012 fell below the corresponding concentration curve for 2011 for both urban and rural areas, and the difference between curves for rural areas was greater than that for urban areas. CONCLUSION: A substantial and increasing gap in health care expenditures existed between urban and rural areas in Anhui. The health care financing inequality merits ample attention, with need for policymaking to focus on improving the accessibility to essential health care services, particularly for rural and poor residents. This study may provide useful information on low income areas of China.

Qualitative study of patients' choice between public and private hospital emergency departments.

OBJECTIVE: The aim of this study was to gather patients' perceptions regarding their choice between public and private hospital EDs for those who hold private health insurance. The findings of this study will contribute to knowledge regarding patients' decision-making processes and therefore may contribute to the development of evidence based public policies. METHODS: An in-depth semi-structured guide was used to interview participants at public and private hospital EDs. Questions sought to identify the issues that were considered by the participants to decide to attend that hospital ED, previous ED experience, expectations of ED services and perceived benefits and barriers to accessing services. Interviews were audio recorded, transcribed verbatim and analysed using content and thematic approaches. RESULTS: Four core themes emerged: prior good experience with the hospital, perceived quality of care, perceived waiting times and perceived costs that may explain patients' choice. Patients' choice between public and private EDs can be explained by the interaction of these core themes. The principal issues appear to be concern for gap payments at private hospital ED and waiting times at public hospital ED. CONCLUSIONS: Patients who choose to attend public EDs appear to value financial concern over waiting time; those who choose to attend private EDs appear to value waiting time ahead of financial concerns.

The Implementation and Evaluation of the Patient Admission Prediction Tool: Assessing Its Impact on Decision-Making Strategies and Patient Flow Outcomes in 2 Australian Hospitals.

STUDY OBJECTIVES: To evaluate the implementation of a Patient Admission Prediction Tool (PAPT) in terms of patient flow outcomes and decision-making strategies. SETTING: The PAPT was implemented in 2 Australian public teaching hospitals during October-December 2010 (hospital A) and October-December 2011 (hospital B). DESIGN: A multisite prospective, comparative (before and after) design was used. Patient flow outcomes measured included access block and hospital occupancy. Daily and weekly data were collected from patient flow reports and routinely collected emergency department information by the site champion and researchers. RESULTS: Daily decision-making strategies ranged from business as usual to use of overcensus beds. Weekly strategies included advanced approval to use of overcensus beds and prebooking nursing staff. These strategies resulted in improved weekend discharges to manage incoming demand for the following week. Following the introduction of the PAPT and workflow guidelines, patient access and hospital occupancy levels could be maintained despite increases in patient presentations (hospital A). CONCLUSIONS: The use of a PAPT, embedded in patient flow management processes and championed by a manager, can benefit bed and staff management. Further research that incorporates wider evaluation of the use of the tool at other sites is warranted.