Exploring the association between surgical out-of-pocket costs and healthcare quality outcomes: A retrospective cohort study.

OBJECTIVES: Rising out-of-pocket (OOP) costs paid by healthcare consumers can inhibit access to necessary healthcare. Yet it is unclear if higher OOP payments are associated with better care quality. This study aimed to identify the individual and socio-contextual predictors of OOP costs and to explore the association between OOP costs and quality of care outcomes for four surgical procedures. METHODS: A retrospective cohort analysis was conducted using data from Medibank Private health insurance members aged ≥18 years who underwent hip replacement, knee replacement, cholecystectomy and radical prostatectomy during 2015-2020 across >300 hospitals in Australia. Healthcare quality outcomes investigated were hospital-acquired complications (HACs), unplanned intensive care unit (ICU) admissions, prolonged length of stay (LOS) and readmissions within 28 days. Socio-contextual determinants of OOP costs examined were patient demographics, socioeconomic status, health insurance, and procedure complexity. Generalized linear mixed modelling examined the risk of each outcome, adjusting for covariates and considering patients clustering within surgeons and hospitals. RESULTS: Patients were more likely to pay OOP costs if they were aged 65-74 years compared to aged 18-44 years for all four surgical procedures. No association between OOP payments and the risk of HACs, ICU admission, or hospital readmission was identified. Patients who paid OOP costs were less likely to have a prolonged LOS for all four procedure types. CONCLUSIONS: Higher OOP payments weren't linked to improved care quality except for shorter hospital stays. Greater transparency on OOP costs is needed to inform consumer decisions.

Co-designing strategies to improve advance care planning among people from culturally and linguistically diverse backgrounds with cancer: iCanCarePlan study protocol.

BACKGROUND: Advance care planning (ACP) describes the process of supporting individuals at any age or stage of health to consider and share their personal values, life goals, and preferences regarding future health care. Engaging in ACP is associated with better-quality of care in which people receive care in lines with their wishes, values and preferences. Direct translations of ACP guides and resources do not attend to the considerable inter- and intra-ethnic variations in cultural and religious or spiritual beliefs that shape preferences among people from culturally and linguistically diverse (CALD) backgrounds. ICanCarePlan is a three-year project that aims to determine the prevalence of ACP documentation among people from CALD backgrounds with cancer, identify resources available and their use to support ACP among CALD communities, identify barriers and facilitators of person-centred ACP, and to develop, through co-design with consumers and clinicians, approaches that enhance the process ACP for people from CALD backgrounds. METHOD: A mixed-method sequential approach will be used comprising of four studies. Study one is retrospective medical record review of approximately 1500 medical records to establish the prevalence of ACP documentation among CALD patient records in cancer services. Study two is a document analysis synthesising the resources available in the Australian health system to support ACP. Study three is a qualitative study with healthcare staff and consumers to explore barriers and enablers of person-centred ACP. Evidence generated from studies one to three will inform the conduct of co-design with stakeholders to develop approaches to improve ACP processes among CALD communities. Language, technical and financial support for meaningful involvement with consumers from CALD backgrounds throughout this project is outlined. A plan for distress management is also made due to sensitive nature of the topic. The research project has also established a project steering group consisting of three consumer members who are from CALD backgrounds. DISCUSSION: The project will address a national priority issue for a growing population of CALD communities in Australia. The project will provide novel evidence of ACP among CALD communities and novel strategies developed with stakeholders to enhance uptake and experiences of ACP.

Measuring clinician experience in value-based healthcare initiatives: a 10-item core clinician experience measure (CEM-10).

Objective Clinician's experiences of providing care are identified as a key outcome associated with value-based healthcare (VBHC). In contrast to patient-reported experience measures, measurement tools to capture clinician's experiences in relation to VBHC initiatives have received limited attention to date. Progressing from an initial 18-item clinician experience measure (CEM), we sought to develop and evaluate the reliability of a set of 10 core clinician experience measure items in the CEM-10. Methods A multi-method project was conducted using a consensus workshop with clinicians from a range of NSW Health local health districts to reduce the 18-item CEM to a short form 10-item core clinician experience measure (CEM-10). The CEM-10 was deployed with clinicians providing diabetes care, care for older adults and virtual care across all districts and care settings of New South Wales, Australia. Psychometric analysis was used to determine the internal consistency of the tool and its suitability for diverse clinical contexts. Results Consensus building sessions led to a rationalised 10-item tool, retaining the four domains of psychological safety (two items), quality of care (three items), clinician engagement (three items) and interprofessional collaboration (two items). Data from four clinician cohorts (n = 1029) demonstrated that the CEM-10 four-factor model produced a good fit to the data and high levels of reliability, with factor loadings ranging from 0.77 to 0.92, with Cronbach's alpha (range: 0.79-0.90) and composite reliability (range: 0.80-0.92). Conclusions The CEM-10 provides a core set of common clinician experience measurement items that can be used to compare clinician's experiences of providing care between and within cohorts. The CEM-10 may be supported by additional items relevant to particular initiatives when evaluating VBHC outcomes.

Marked variations in medical provider and out-of-pocket costs for radical prostatectomy procedures in Australia.

Objectives Unwarranted clinical variations in radical prostatectomy (RP) procedures are frequently reported, yet less attention is given to the variations in associated costs. This issue can further widen disparities in access to care and provoke questions about the overall value of the procedure. The present paper aimed to delve into the disparities in hospital, medical provider and out-of-pocket costs for RP procedures in Australia, discussing plausible causes and potential policy opportunities. Methods A retrospective cohort study using Medibank Private claims data for RP procedures conducted in Australian hospitals between 1 January 2015 and 31 December 2020 was undertaken. Results Considerable variations in both medical provider and out-of-pocket costs were observed across the country, with variations evident between different states or territories. Particularly striking were the discrepancies in the costs charged by medical providers, with a notable contrast between the 10th and 90th percentiles revealing a substantial difference of A$9925. Hospitals in Australia exhibited relatively comparable charges for RP procedures. Conclusions Initiatives such as enhancing transparency regarding individual medical provider costs and implementing fee regulations with healthcare providers may be useful in curbing the variations in RP procedure costs.

As loud as a construction site: Noise levels in the emergency department.

BACKGROUND: The Emergency Department (ED), while being an integral part of healthcare systems, frequently experiences noise levels surpassing the World Health Organization's recommended thresholds. These excessive noise levels could considerably compromise the safety and wellbeing of both patients and staff. METHODS: To evaluate noise levels throughout the ED environment, this study utilized dosimeters to measure noise levels over a 24-hour period in six distinct locations, including the ED Waiting Room and Treatment areas. RESULTS: The study found that noise exceeded the WHO recommendations in all six areas of the ED for the entire 24-hour period. Peak noise levels were recorded up to 102.8 dB, which is as loud as noise levels at a construction site. The ED Waiting Room exhibited high peak and average noise levels, indicating the urgent need for quality improvement efforts. These findings align with the results of previous research, thereby suggesting that noise levels in the ED have remained problematic for more than a decade. CONCLUSION: The findings of this study underscore the importance of addressing excessive noise levels in the ED to create a safe and therapeutic hospital environment for both patients and staff. Healthcare organizations must implement proactive measures to address excessive noise levels in the ED.

Is there an association between out-of-pocket hospital costs, quality and care outcomes? A systematic review of contemporary evidence.

BACKGROUND: Out of pocket (OOP) costs vary substantially by health condition, procedure, provider, and service location. Evidence of whether this variation is associated with indicators of healthcare quality and/or health outcomes is lacking. METHODS: The current review aimed to explore whether higher OOP costs translate into better healthcare quality and outcomes for patients in inpatient settings. The review also aimed to identify the population and contextual-level determinants of inpatient out-of-pocket costs. A systematic electronic search of five databases: Scopus, Medline, Psych Info, CINAHL and Embase was conducted between January 2000 to October 2022. Study procedures and reporting complied with PRISMA guidelines. The protocol is available at PROSPERO (CRD42022320763). FINDINGS: A total of nine studies were included in the final review. A variety of quality and health outcomes were examined in the included studies across a range of patient groups and specialities. The scant evidence available and substantial heterogeneity created challenges in establishing the nature of association between OOP costs and healthcare quality and outcomes. Nonetheless, the most consistent finding was no significant association between OOP cost and inpatient quality of care and outcomes. INTERPRETATION: The review findings overall suggest no beneficial effect of higher OOP costs on inpatient quality of care and health outcomes. Further work is needed to elucidate the determinants of OOP hospital costs. FUNDING: This study was funded by Medibank Better Health Foundation.

Cochlear implantation impact on health service utilisation and social outcomes: a systematic review.

BACKGROUND: Hearing loss can have a negative impact on individuals' health and engagement with social activities. Integrated approaches that tackle barriers and social outcomes could mitigate some of these effects for cochlear implants (CI) users. This review aims to synthesise the evidence of the impact of a CI on adults' health service utilisation and social outcomes. METHODS: Five databases (MEDLINE, Scopus, ERIC, CINAHL and PsychINFO) were searched from 1st January 2000 to 16 January 2023 and May 2023. Articles that reported on health service utilisation or social outcomes post-CI in adults aged ≥ 18 years were included. Health service utilisation includes hospital admissions, emergency department (ED) presentations, general practitioner (GP) visits, CI revision surgery and pharmaceutical use. Social outcomes include education, autonomy, social participation, training, disability, social housing, social welfare benefits, occupation, employment, income level, anxiety, depression, quality of life (QoL), communication and cognition. Searched articles were screened in two stages ̶̶̶ by going through the title and abstract then full text. Information extracted from the included studies was narratively synthesised. RESULTS: There were 44 studies included in this review, with 20 (45.5%) cohort studies, 18 (40.9%) cross-sectional and six (13.6%) qualitative studies. Nine studies (20.5%) reported on health service utilisation and 35 (79.5%) on social outcomes. Five out of nine studies showed benefits of CI in improving adults' health service utilisation including reduced use of prescription medication, reduced number of surgical and audiological visits. Most of the studies 27 (77.1%) revealed improvements for at least one social outcome, such as work or employment 18 (85.7%), social participation 14 (93.3%), autonomy 8 (88.9%), education (all nine studies), perceived hearing disability (five out of six studies) and income (all three studies) post-CI. None of the included studies had a low risk of bias. CONCLUSIONS: This review identified beneficial impacts of CI in improving adults' health service utilisation and social outcomes. Improvement in hearing enhanced social interactions and working lives. There is a need for large scale, well-designed epidemiological studies examining health and social outcomes post-CI.

What types of green space disrupt a lonelygenic environment? A cohort study.

INTRODUCTION: Associations between green space type and social loneliness (a scarcity of people one feels they can depend on) were investigated in city-living participants in the Sax Institute's 45 and Up Study. METHODS: Availability of green space, tree canopy and open grass were measured as a percentage of land-use within 1.6 km road-network distance buffers using high-resolution data. Multilevel logistic regressions adjusted for confounding tested associations between each green space indicator with the odds of social loneliness at baseline (prevalence) and follow-up (incidence), adjusted for demographic and socioeconomic confounders. RESULTS: The prevalence of social loneliness at baseline was 5.3% (n = 5627 /105,498). Incidence of social loneliness at follow-up was 3.4% (n = 1772/51,365). Adjusted regressions indicated reduced odds of prevalent (OR = 0.95, 95%CI = 0.92-0.98) and incident social loneliness with 10% more green space (OR = 0.92, 95%CI = 0.90- 0.96). Similar associations were found with a 10% increase in tree canopy for both prevalent (OR = 0.92, 95%CI = 0.88-0.95) and incident social loneliness (OR = 0.92, 95%CI = 0.88-0.97). Two-way interaction terms indicated effect modification by sex but not couple status. Among women, a 10% increase in total green space was associated with lower odds of prevalent (OR = 0.95, 0.91-0.95) and incident (OR = 0.89, 0.85-0.95) social loneliness. A 10% increase in tree canopy among women was associated with lower odds of prevalent (OR = 0.89, 085-0.92) and incident (OR = 0.85, 0.80-0.92) social loneliness. Meanwhile, a 10% increase in open grass among women was associated with higher odds of prevalent (OR = 1.08, 1.01-1.15) and incident (OR = 1.19, 1.03-1.35) social loneliness. Associations for men were statistically significant for a 10% increase in total green space (OR = 0.96, 0.92-0.99) and tree canopy (OR = 0.93, 0.90-0.97) for prevalent social loneliness only. CONCLUSION: Urban greening and tree canopy restoration may reduce risks of social loneliness, perhaps especially in women.

ARCHS: adult recipients of cochlear implants: health and social long-term outcomes-a state-specific and national population-based retrospective cohort study protocol.

INTRODUCTION: While the majority of adults with severe-to-profound hearing loss and poor speech perception outcomes with hearing aids benefit from receiving a cochlear implant, the long-term health and social benefits for implant recipients are yet to be explored. The objective of the ARCHS research is to provide a better understanding of the health and social factors that play a role in the lives of adults with a cochlear implant up to 10 years after the procedure. METHOD AND ANALYSIS: This research will involve conducting two retrospective cohort studies of adults aged ≥18 years who received a cochlear implant during 2011-2021 using linked administrative data first within New South Wales (NSW) and second Australia-wide. It will examine health service use and compare health and social outcomes for younger (18-64 years) and older (≥65 years) cochlear implant recipients. ETHICS AND DISSEMINATION: Ethical approval was received from the NSW Population Health Services Research Ethics Committee for the NSW cohort study (Reference: 2022/ETH00382/2022.07) and from the Macquarie University ethics committee for the national cohort study (Reference: 520221151437084). Research findings will be published in peer-reviewed journals and presented at scientific conferences.

Green space and loneliness: A systematic review with theoretical and methodological guidance for future research.

Persistent loneliness troubles people across the life span, with prevalence as high as 61 % in some groups. Urban greening may help to reduce the population health impacts of loneliness and its concomitants, such as hopelessness and despair. However, the literature lacks both a critical appraisal of extant evidence and a conceptual model to explain how green space would work as a structural intervention. Both are needed to guide decision making and further research. We conducted a systematic review of quantitative studies testing associations between green space and loneliness, searching seven databases. Twenty two studies were identified by 25/01/2022. Most of the studies were conducted in high-income countries and fifteen (68 %) had cross-sectional designs. Green space was measured inconsistently using either objective or subjective indicators. Few studies examined specific green space types or qualities. The majority of studies measured general loneliness (e.g. using the UCLA loneliness scale). Different types of loneliness (social, emotional, existential) were not analysed. Of 132 associations, 88 (66.6 %) indicated potential protection from green space against loneliness, with 44 (33.3 %) reaching statistical significance (p < 0.05). We integrated these findings with evidence from qualitative studies to elaborate and extend the existing pathway domain model linking green space and health. These elaborations and extensions acknowledge the following: (a) different types of green space have implications for different types of loneliness; (b) multilevel circumstances influence the likelihood a person will benefit or suffer harm from green space; (c) personal, relational, and collective processes operate within different domains of pathways linking green space with loneliness and its concomitants; (d) loneliness and its concomitants are explicitly positioned as mediators within the broader causal system that links green space with health and wellbeing. This review and model provide guidance for decision making and further epidemiological research on green space and loneliness.

Green space and cardiovascular health in people with type 2 diabetes.

Associations between green space type and 9-year risk of incident cardiovascular disease (CVD) hospitalisations and deaths were analysed in 4166 people with type 2 diabetes in the Sax Institute's 45 and Up Study. Incidence of all-cause mortality, cardiovascular mortality, fatal or non-fatal CVD events and acute myocardial infarctions (AMI) were 14.67%, 7.23%, 47.36%, and 4.51%, respectively. After full adjustment, more tree canopy was associated with lower CVD mortality, lower fatal or non-fatal CVD events, and lower AMI risk. More open grass was associated with lower all-cause mortality, lower CVD mortality and lower fatal or non-fatal CVD events, but higher AMI risk.

Neighborhood Environment and Type 2 Diabetes Comorbidity in Serious Mental Illness.

Aim: The aim of this study was to examine the association between neighborhood characteristics and type 2 diabetes (T2D) comorbidity in serious mental illness (SMI). We investigated associations of neighborhood-level crime, accessibility to health care services, availability of green spaces, neighborhood obesity, and fast food availability with SMI-T2D comorbidity. Method: A series of multilevel logistic regression models accounting for neighborhood-level clustering were used to examine the associations between 5 neighborhood variables and SMI-T2D comorbidity, sequentially adjusting for individual-level variables and neighborhood-level socioeconomic disadvantage. Results: Individuals with SMI residing in areas with higher crime rates per 1000 population had 2.5 times increased odds of reporting T2D comorbidity compared to the individuals with SMI residing in lower crime rate areas after controlling for individual and areal level factors (95% CI 0.91-6.74). There was no evidence of association between SMI-T2D comorbidity and other neighborhood variables investigated. Conclusion: Public health strategies to reduce SMI-T2D comorbidity might benefit by targeting on individuals with SMI living in high-crime neighborhoods. Future research incorporating longitudinal designs and/or mediation analysis are warranted to fully elucidate the mechanisms of association between neighborhoods and SMI-T2D comorbidity.

Exploring the geography of serious mental illness and type 2 diabetes comorbidity in Illawarra-Shoalhaven, Australia (2010 -2017).

OBJECTIVES: The primary aim of this study was to describe the geography of serious mental illness (SMI)-type 2 diabetes comorbidity (T2D) in the Illawarra-Shoalhaven region of NSW, Australia. The Secondary objective was to determine the geographic concordance if any, between the comorbidity and the single diagnosis of SMI and diabetes. METHODS: Spatial analytical techniques were applied to clinical data to explore the above objectives. The geographic variation in comorbidity was determined by Moran's I at the global level and the local clusters of significance were determined by Local Moran's I and spatial scan statistic. Choropleth hotspot maps and spatial scan statistics were generated to assess the geographic convergence of SMI, diabetes and their comorbidity. Additionally, we used bivariate LISA (Local Indicators of Spatial Association) and multivariate spatial scan to identify coincident areas with higher rates of both SMI and T2D. RESULTS: The study identified significant geographic variation in the distribution of SMI-T2D comorbidity in Illawarra Shoalhaven. Consistently higher burden of comorbidity was observed in some urban suburbs surrounding the major metropolitan city. Comparison of comorbidity hotspots with the hotspots of single diagnosis SMI and T2D further revealed a geographic concordance of high-risk areas again in the urban areas outside the major metropolitan city. CONCLUSION: The identified comorbidity hotspots in our study may serve as a basis for future prioritisation and targeted interventions. Further investigation is required to determine whether contextual environmental factors, such as neighbourhood socioeconomic disadvantage, may be explanatory. IMPLICATIONS FOR PUBLIC HEALTH: Ours is the first study to explore the geographic variations in the distribution of SMI and T2D comorbidity. Findings highlight the importance of considering the role of neighbourhood environments in influencing the T2D risk in people with SMI.

Examining the Association between Neighbourhood Socioeconomic Disadvantage and Type 2 Diabetes Comorbidity in Serious Mental Illness.

This study examined the association between neighbourhood socioeconomic disadvantage and serious mental illness (SMI)-type 2 diabetes (T2D) comorbidity in an Australian population using routinely collected clinical data. We hypothesised that neighbourhood socioeconomic disadvantage is positively associated with T2D comorbidity in SMI. The analysis considered 3816 individuals with an SMI living in the Illawarra and Shoalhaven regions of NSW, Australia, between 2010 and 2017. Multilevel logistic regression models accounting for suburb (neighbourhood) level clustering were used to assess the association between neighbourhood disadvantage and SMI -T2D comorbidity. Models were adjusted for age, sex, and country of birth. Compared with the most advantaged neighbourhoods, residents in the most disadvantaged neighbourhoods had 3.2 times greater odds of having SMI-T2D comorbidity even after controlling for confounding factors (OR 3.20, 95% CI 1.42-7.20). The analysis also revealed significant geographic variation in the distribution of SMI -T2D comorbidity in our sample (Median Odds Ratio = 1.35) Neighbourhood socioeconomic disadvantage accounted for approximately 17.3% of this geographic variation. These findings indicate a potentially important role for geographically targeted initiatives designed to enhance prevention and management of SMI-T2D comorbidity in disadvantaged communities.

Geographic and area-level socioeconomic variation in cardiometabolic risk factor distribution: a systematic review of the literature.

INTRODUCTION: A growing number of publications report variation in the distribution of cardiometabolic risk factors (CMRFs) at different geographic scales. A review of these variations may help inform policy and health service organisation. AIM: To review studies reporting variation in the geographic distribution of CMRFs and its association with various proxy measures of area-level socioeconomic disadvantage (ASED) among the adult ( ≥ 18 years) population across the world. METHODS: A systematic search for published articles was conducted in four databases (MEDLINE (Ovid), PubMed, Scopus and Web of Science) considering the interdisciplinary nature of the review question. Population-based cross-sectional and cohort studies on geographic variations of one or more biological proxies of CMRFs with/without an analysed contextual association with ASED were included. Two independent reviewers screened the studies and PRISMA guidelines were followed in the study selection and reporting. RESULT: A total of 265 studies were retrieved and screened, resulting in 24 eligible studies. The review revealed reports of variation in the distribution of CMRFs, at varying geographic scales, in multiple countries. In addition, consistent associations between ASED and higher prevalence of CMRFs were demonstrated. The reports were mainly from industrialised nations and small area geographic units were frequently used. CONCLUSION: Geographic variation in cardiometabolic risk exists across multiple spatial scales and is positively associated with ASED. This association is independent of individual-level factors and provides an imperative for area-based approaches to informing policy and health service organisation. The study protocol is registered in International prospective register of systematic reviews (Register No: CRD42018115294) PROSPERO 2018.

Serious Mental Illness, Neighborhood Disadvantage, and Type 2 Diabetes Risk: A Systematic Review of the Literature.

AIM OF THE STUDY: This review aims to systematically synthesize the body of literature examining the association between neighborhood socioeconomic disadvantage and serious mental illness (SMI)-type 2 diabetes (T2D) co-occurrence. METHODS: We conducted an electronic search of four databases: PubMed, Scopus, Medline, and Web of Science. Studies were considered eligible if they were published in English, peer reviewed, quantitative, and focused on the association between neighborhood disadvantage and SMI-T2D comorbidity. Study conduct and reporting complied with PRISMA guidelines, and the protocol is made available at PROSPERO (CRD42017083483). RESULTS: The one eligible study identified reported a higher burden of T2D in persons with SMI but provided only a tentative support for the association between neighborhood disadvantage and SMI-T2D co-occurrence. CONCLUSION: Research into neighborhood effects on SMI-T2D comorbidity is still in its infancy and the available evidence inconclusive. This points to an urgent need for attention to the knowledge gap in this important area of public health. Further research is needed to understand the health resource implications of the association between neighborhood deprivation and SMI-T2D comorbidity and the casual pathways linking them.