The efficiency, timeliness, health outcomes and cost-effectiveness of a new aeromedical retrieval model in Central Australia: A pre- and post-implementation observational study.

OBJECTIVE: To assess timeliness, efficiency, health outcomes and cost-effectiveness of the 2018 redesigned Central Australian aeromedical retrieval model. DESIGN: Pre- and postimplementation observational study of all patients receiving telehealth consultations from remote medical practitioners (RMPs) or Medical Retrieval and Consultation Centre (MRaCC) physicians between 1/1/2015 and 29/2/2020. Descriptive and inferential statistics measuring system efficiency, timeliness, health outcomes and incremental cost-effectiveness. FINDINGS: There were 9%-10% reductions in rates of total aeromedical retrievals, emergency department admissions and hospitalisations postimplementation, all p-values < 0.001. Usage rates for total hospital bed days and ICU hours were 17% lower (both p < 0.001). After adjusting for periodicity (12% fewer retrievals on weekends), each postimplementation year, there were 0.7 fewer retrievals/day (p = 0.002). The mean time from initial consultation to aeromedical departure declined by 18 minutes post-implementation (115 vs. 97 min, p = 0.007). The hazard of death within 365 days was nonsignificant (0.912, 95% CI 0.743-1.120). Postimplementation, it cost $302 more per hospital admission and $3051 more per year of life saved, with a 75% probability of cost-effectiveness. These costs excluded estimated savings of $744,528/year in reduced hospitalisations and the substantial social and out-of-pocket costs to patients and their families associated with temporary relocation to Alice Springs. CONCLUSION: Central Australia's new critical care consultant-led aeromedical retrieval model is more efficient, is dispatched faster and is more cost-effective. These findings are highly relevant to other remote regions in Australia and internationally that have comparable GP-led retrieval services.

Evaluation of a new medical retrieval and primary health care advice model in Central Australia: Results of pre- and post-implementation surveys.

INTRODUCTION: In February 2018 the Remote Medical Practitioner (RMP)-led telehealth model for providing both primary care advice and aeromedical retrievals in Central Australia was replaced by the Medical Retrieval and Consultation Centre (MRaCC) and Remote Outreach Consultation Centre (ROCC). In this new model, specialists with advanced critical care skills provide telehealth consultations for emergencies 24/7 and afterhours primary care advice (MRaCC) while RMPs (general practitioners) provide primary care telehealth advice in business hours via the separate ROCC. OBJECTIVE: To evaluate changes in clinicians' perceptions of efficiency and timeliness of the new (MRaCC) and (ROCC) model in Central Australia. DESIGN: There were 103 and 72 respondents, respectively, to pre- and post-implementation surveys of remote clinicians and specialist staff. FINDINGS: Both emergency and primary care aspects of telehealth support were perceived as being significantly more timely and efficient under the newly introduced MRaCC/ROCC model. Importantly, health professionals in remote community were more likely to feel that their access to clinical support during emergencies was consistent and immediately available. DISCUSSION: Respondents consistently perceived the new MRaCC/ROCC model more favourably than the previous RMP-led model, suggesting that there are benefits to having separate referral streams for telehealth advice for primary health care and emergencies, and staffing the emergency stream with specialists with advanced critical care skills. CONCLUSION: Given the paucity of literature about optimal models for providing pre-hospital medical care to remote residents, the findings have substantial local, national and international relevance and implications, particularly in similar geographically large countries, with low population density.

Optimising medical retrieval processes and outcomes in remote areas in high-income countries: A scoping review.

OBJECTIVE: This scoping review explores the structure and process-level strategies that are associated with medical retrieval outcomes. A secondary aim is to identify the range of medical retrieval outcomes used to assess the performance of remote retrieval services. DESIGN: A scoping review of peer-reviewed literature from PubMed, CINAHL and the Web of Science was undertaken following guidelines set by the Johanna Briggs Institute manual for scoping reviews. All articles were assessed by two reviewers. Themes were derived inductively from the data extracted. SETTING: Medical retrievals in sparsely populated remote locations in high-income countries. PARTICIPANTS: Staff and clients of remote medical retrieval services. INTERVENTIONS: Structures and processes (e.g. resource availability, retrieval staff structures and governance protocols) that aimed to improve medical retrieval outcomes. OUTCOMES: Patient health outcomes and service efficiency. RESULTS: Twenty-four articles were included. Three broad themes, related to the nature of the interventions, were included: optimising prehospital management of retrievals, staffing and resourcing of retrieval services and retrieval model evaluation. Mortality was the most frequently used outcome indicator in these studies, but was not measured consistently across studies. CONCLUSIONS: This review highlights significant gaps in the literature that describes the structure and processes of retrieval models operating in remote areas and a dearth of literature evaluating specific operational strategies implemented within medical retrieval models. The available literature does not meaningfully assist with identifying key outcome indicators for developing a consistent monitoring and evaluation framework for retrieval services in geographically, culturally and demographically diverse remote contexts.

Phased implementation of pathogen-reduced platelets in a health system facilitates increased manufacturing at the blood center.

BACKGROUND: Pathogen reduction treatment (PRT) reduces the risk of transfusion-transmitted infections from established and emerging organisms. Manufacturing, however, is complex. In our university health system, we phased in pathogen-reduced platelets (PR PLTs) by patient population. We then assessed the implementation strategy and investigated factors in the supply chain that prevented us from meeting the goal of providing greater than 90% PR PLTs within 6 months. STUDY DESIGN AND METHODS: In Phase 1, PR PLTs were provided in the outpatient cancer center. Phase 2 added inpatients undergoing bone marrow transplantation, and Phase 3 included all patients. In Phase 4, the blood center implemented manufacturing optimization strategies. Product supply and usage during the first 23 months after implementation were evaluated. Investigation of the supply chain included analysis of (1) the number of in-state hospitals receiving PR PLTs; (2) the fraction of products eligible for PRT before and after manufacturing improvements. RESULTS: During Phases 1 and 2, PR products comprised 44% and 53% of PLTs transfused in the phased-in areas. At 6 months, 41% of PLTs were PR, and at 23 months, 92%. The fraction of PR PLTs transfused in our system correlated logarithmically with the number of in-state hospitals receiving them (R2 = 0.71) and the number of PR PLTs sold to those hospitals (R2 = 0.80). CONCLUSION: Phased implementation is a practical and ethical way to introduce PR PLTs in a health system and facilitates scalability at the blood center. Widespread availability of PR products may require collective action and can be increased by optimization strategies during manufacturing.

Community outreach midwifery-led model improves antenatal access in a disadvantaged population.

OBJECTIVE: This study aimed to assess the impact of a new model of antenatal care for women living in a very remote area. DESIGN: This is a retrospective 2-year evaluation of antenatal care. SETTING AND PARTICIPANTS: Two hundred thirteen pregnant women in Aboriginal communities in the Fitzroy Valley of Western Australia participated in this study. INTERVENTION: The implementation of a midwifery-led interdisciplinary model of antenatal outreach care. MAIN OUTCOME MEASURES: The indicators measured were numbers of antenatal visits, their location and quality care indicators (presentation in first trimester, alcohol and smoking, ultrasound and blood-borne virus screening) and outcome indicators (birth weight, prematurity, in utero deaths and mode of delivery). RESULTS: There was an increase in access to antenatal care and improvements in quality-of-care indicators. The proportion of visits provided in local Aboriginal communities increased from 10% to 24%. There were statistically significant increases in women presenting in the first trimester (40-58%), screening for alcohol and smoking (48-93%) and having an ultrasound in pregnancy (59-94%). There were no significant improvements in neonatal outcome indicators. CONCLUSION: There is a large disparity in maternal and child health outcomes between Aboriginal and Torres Strait Islander (Indigenous) and non-Indigenous Australians thought to be due to decreased access to antenatal care, poorer socioeconomic status and the associated risk factors. The change in model of care resulted in earlier presentation for antenatal care, increased numbers of antenatal visits and increased screening for risk factors. Regular auditing of services enables the identification of opportunity for improvement with the goal of improving health outcomes.

Strengthening primary health care: achieving health gains in a remote region of Australia.

OBJECTIVE: To evaluate the impact of a comprehensive primary health care service model on key health performance indicators in a remote region of Australia. DESIGN AND SETTING: A cross-sectional 6-year retrospective evaluation of the results of a health service partnership between an Aboriginal community controlled health service, a hospital and a community health service in north-west Western Australia. INTERVENTION: Integration of health promotion, health assessments and chronic disease management with an acute primary health care service as a result of the formal partnership. MAIN OUTCOME MEASURES: Cross-sectional data on use and outcomes of health care from 1 July 2006 to 30 June 2012 are reported in accordance with national key performance indicators. RESULTS: There were increases in occasions of service (from 21 218 to 33 753), most notably in primary health care services provided to very remote outlying communities (from 863 to 11 338). Health assessment uptake increased from 13% of the eligible population to 61%, leading to 73% of those identified with diabetes being placed on a care plan. Quality-of-care indicators (glycated haemoglobin checks and proportion of people with diabetics receiving antihypertensives) showed improvements over the 6-year study period, and there was also a downward trend in mortality. CONCLUSIONS: This study demonstrates that strengthening primary health care services by addressing key enablers and sustainability requirements can translate into population health gains consistent with the goals underpinning the National Health Care Reform and Closing the Gap policies, and may potentially reduce health inequity for remote-living Aboriginal Australians.

Prevalence of airflow obstruction and reduced forced vital capacity in an Aboriginal Australian population: The cross-sectional BOLD study.

BACKGROUND AND OBJECTIVE: Mortality and hospital separation data suggest a higher burden of chronic obstructive pulmonary disease (COPD) in indigenous than non-indigenous subpopulations of high-income countries. This study sought to accurately measure the true prevalence of post-bronchodilator airflow obstruction and forced vital capacity reduction in representative samples of Indigenous and non-Indigenous Australians. METHODS: This study applies cross-sectional population-based survey of Aboriginal and non-Indigenous residents of the Kimberley region of Western Australia aged 40 years or older, following the international Burden Of Lung Disease (BOLD) protocol. Quality-controlled spirometry was conducted before and after bronchodilator. COPD was defined as Global initiative for chronic Obstructive Lung Disease (GOLD) Stage 2 and above (post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1 /FVC) ratio <0.7 and FEV1 < 80% predicted). RESULTS: Complete data were available for 704 participants. The prevalence of COPD, adjusted for age, gender and body weight in Aboriginal participants (7.2%, 95% confidence interval (CI) 3.9 to 10.4) was similar to that seen in non-Indigenous Kimberley participants (8.2%, 95% CI 5.7 to 10.7) and non-Indigenous residents of the remainder of Australia (7.1%, 95% CI 6.1 to 8.0). The prevalence of low FVC (<80% predicted) was substantially higher in Aboriginal compared with non-Indigenous participants (74.0%, 95% CI 69.1 to 78.8, vs 9.7%, 95% CI 7.1 to 12.4). CONCLUSIONS: Low FVC, rather than airflow obstruction, characterizes the impact of chronic lung disease previously attributed to COPD in this population subject to significant social and economic disadvantage. Environmental risk factors other than smoking as well as developmental factors must be considered. These findings require further investigation and have implications for future prevention of chronic lung disease in similar populations.

Evaluation of an ear health pathway in remote communities: improvements in ear health access.

OBJECTIVE: Reduce long waiting lists for ear, nose and throat (ENT) specialist review and improve primary ear health care. DESIGN: A retrospective evaluation of ear health care after the implementation of an ear health program (EHP). SETTING AND PARTICIPANTS: School children in Aboriginal communities in the Fitzroy Valley of Western Australia. KEY MEASURES FOR IMPROVEMENT: Access number of children screened for ear disease, effectiveness-referral letter completeness (history, otoscopy, tympanometry, audiometry), patient management and waiting time until first ENT contact. INTERVENTIONS: EHP--an electronic referral template, ear health nurse, ear health educator and telehealth ENT specialist review. MAIN OUTCOME MEASURES: Screening rates, timely ENT review and improved primary care management. RESULTS: Number of children screened increased from 148 per 18 months to 710. Nearly twofold increase in numbers of patients referred to ENT (32, 66). A reduction in median waiting time from 141 days to 22 days for ENT review using telehealth. Content of referral letters showed an increase in essential information--otoscopy, audiometry and tympanometry. Primary care management in accordance with guidelines improved. CONCLUSIONS: The addition of an ear health team increased access to appropriate primary care management and the time to contact with ENT was reduced by using an electronic template and telehealth sessions.

Management of type 2 diabetes - a community partnership approach.

BACKGROUND: The impact of type 2 diabetes is severe in Aboriginal and Torres Strait Islander people. The Fitzroy Valley, a remote region of the Kimberley in Western Australia, has a high population of Indigenous Australians. An effective community partnership has been formed between the local hospital, the population health service and local health services. OBJECTIVE: This article describes the evaluation of a new model of partnership care using an audit cycle. Results Statistically significant improvements in foot examination, body mass index, urine albumin creatinine ratio, total cholesterol, triglycerides and visual acuity measurements were observed. Significant increases in the proportion of patients achieving cholesterol and triglycerides therapeutic targets occurred. Most other outcome indicators demonstrated a nonsignificant improvement, which may be due to the short time interval in the audit for potential change. CONCLUSION: A dedicated chronic disease team and a clinical information system to coordinate culturally appropriate, multidisciplinary chronic disease care enables effective management of chronic diseases such as type 2 diabetes.

Lymphatic filariasis in Papua New Guinea: distribution at district level and impact of mass drug administration, 1980 to 2011.

BACKGROUND: Lymphatic filariasis (LF) caused by Wuchereria bancrofti is present at high prevalence in some parts of Papua New Guinea. However, there has been no rigorous data-based representative assessment of nationwide prevalence of LF. The LF programme has been daunted by the scope of the problem, and progress on mass drug administration (MDA) has been slow and lacking in resources. METHODS: A systematic literature review identified LF surveys in Papua New Guinea between 1980 and 2011. Results were extracted by location, time period and test used (blood slide, immunochromatographic test (ICT) or Og4C3 ELISA) and combined by district. Three criteria schemes based on the Global Programme to Eliminate Lymphatic Filariasis guidelines, with modifications, were developed to classify and prioritize districts by prevalence level. Results of repeated surveys in the same sites were used to investigate the impact of MDA on LF prevalence over the time period. RESULTS: There were 312 distinct survey sites identified in 80 of the 89 districts over the 31-year period. The overall LF prevalence in the sites tested was estimated at 18.5 to 27.5% by blood slide for microfilariae (Mf), 10.1% to 12.9% by ICT and 45.4% to 48.8% by Og4C3. Biases in site selection towards areas with LF, and change in type of assay used, affected the prevalence estimates, but overall decline in prevalence over the time period was observed. Depending on the criteria used, 34 to 36 districts (population 2.7 to 2.9 million) were classed as high endemic (≥5% prevalence), 15 to 25 districts (1.7 to 1.9 million) as low endemic (<5%) and 20 to 31 (1.3 to 2.2 million) as non-endemic. Nine districts (0.7 million) had no information. The strong impact of MDA, especially on microfilaria (Mf) prevalence, was noted in sites with repeat surveys. CONCLUSIONS: This analytical review of past surveys of LF in Papua New Guinea enables better estimation of the national burden, identifies gaps in knowledge, quantifies and locates the population at risk, and can be used to predict the likely impact of MDA and/or vector control. Better targeting of districts by level of prevalence will strengthen the control programme, facilitate monitoring of the disease trend and increase the likelihood of reaching the target of LF elimination by 2020.

Short communication: a simple method for performing worm-egg counts on sodium acetate formaldehyde-preserved samples.

The Kato Katz method is the most common way of performing worm-egg counts on human faecal samples, but it must be done in the field using freshly collected samples. This makes it difficult to use in remote, poorly accessible situations. This paper describes a simple method for egg counts on preserved samples collected in the field and sent to a central location for further processing.

Predicting respiratory syncytial virus hospitalisation in Australian children.

BACKGROUND: There is limited information on respiratory syncytial virus infections among Australians, particularly those of Indigenous descent. AIM: This study identifies groups of infants at risk of hospitalisation with respiratory syncytial virus-positive lower respiratory tract infection who may be targeted for prevention with palivizumab. METHODS: Case control study: the case notes of 271 children with cases of respiratory syncytial virus-positive lower respiratory tract infection admitted to The Townsville Hospital were studied for risk factors. Controls were chosen randomly from babies born in The Townsville Hospital during that period. Multiple logistic regression analysis and classification and regression tree analysis were used to identify risk factors. RESULTS: Multiple logistic regression analysis identified birthweight <2500 g, maternal parity and marital status to be independent predictors of hospitalisation with respiratory syncytial virus-positive lower respiratory tract infection. Classification and regression tree analysis identified babies born weighing <2500 g who possessed older siblings to be at highest risk. Single mothers and smoking were additional risk factors. Indigenous babies were significantly more likely to be exposed to all of the identified risk factors. CONCLUSION: Babies born weighing <2500 g (especially with siblings) could be targeted for prevention. All Indigenous babies should be considered at high risk because of their exposure to multiple risk factors.

Cost-effectiveness of respiratory syncytial virus prophylaxis with palivizumab.

BACKGROUND: A monoclonal antibody, palivizumab, directed against respiratory syncytial virus (RSV) has been shown to decrease hospitalisation rates. Because of its expense, the cost-effectiveness of this agent should be determined for high-risk groups. AIM: To determine characteristics of RSV infection in Townsville and the economic feasibility of palivizumab immunoprophylaxis in high-risk groups. METHODS: Cases of RSV-positive bronchiolitis were retrospectively identified. Cases were grouped according to recognised risk factors. The hypothetical costs of palivizumab immunoprophylaxis for infants at risk were calculated. RESULTS: The rate of hospitalisation with RSV-positive lower respiratory tract infection was 22 per 1000 live births but increased to 50 per 1000 among Indigenous babies born weighing <2500 g. The cost of preventing an admission in each of the identified high-risk groups, based on drug costs alone, ranged from AD 69,861 to AD 88,547. CONCLUSION: Palivizumab was not cost-effective in the prophylaxis of RSV in the high-risk group of infants tested here.