Do patients have a say? A narrative review of the development of patient-reported outcome measures used in elective procedures for coronary revascularisation.

PURPOSE: Patient-reported outcome measures (PROMs) capture health information from the patient's perspective that can be used when weighing up benefits, risks and costs of treatment. This is important for elective procedures such as those for coronary revascularisation. Patients should be involved in the development of PROMs to accurately capture outcomes that are important for the patient. The aims of this review are to identify if patients were involved in the development of cardiovascular-specific PROMs used for assessing outcomes from elective coronary revascularisation, and to explore what methods were used to capture patient perspectives. METHODS: PROMs for evaluating outcomes from elective coronary revascularisation were identified from a previous review and an updated systematic search. The studies describing the development of the PROMs were reviewed for information on patient input in their conceptual and/or item development. RESULTS: 24 PROMs were identified from a previous review and three additional PROMs were identified from the updated search. Full texts were obtained for 26 of the 27 PROMs. The 26 studies (11 multidimensional, 15 unidimensional) were reviewed. Only nine studies reported developing PROMs using patient input. For eight PROMs, the inclusion of patient input could not be judged due to insufficient information in the full text. CONCLUSIONS: Only nine of the 26 reviewed PROMs used in elective coronary revascularisation reported involving patients in their conceptual and/or item development, while patient input was unclear for eight PROMs. These findings suggest that the patient's perspective is often overlooked or poorly described in the development of PROMs.

Reasons why specialist doctors undertake rural outreach services: an Australian cross-sectional study.

BACKGROUND: The purpose of the study is to explore the reasons why specialist doctors travel to provide regular rural outreach services, and whether reasons relate to (1) salaried or private fee-for-service practice and (2) providing rural outreach services in more remote locations. METHODS: A national cross-sectional study of specialist doctors from the Medicine in Australia: Balancing Employment and Life (MABEL) survey in 2014 was implemented. Specialists providing rural outreach services self-reported on a 5-point scale their level of agreement with five reasons for participating. Chi-squared analysis tested association between agreement and variables of interest. RESULTS: Of 567 specialists undertaking rural outreach services, reasons for participating include to grow the practice (54%), maintain a regional connection (26%), provide complex healthcare (18%), healthcare for disadvantaged people (12%) and support rural staff (6%). Salaried specialists more commonly participated to grow the practice compared with specialists in fee-for-service practice (68 vs 49%). This reason was also related to travelling further and providing outreach services in outer regional/remote locations. Private fee-for-service specialists more commonly undertook outreach services to provide complex healthcare (22 vs 14%). CONCLUSIONS: Specialist doctors undertake rural outreach services for a range of reasons, mainly to complement the growth and diversity of their main practice or maintain a regional connection. Structuring rural outreach around the specialist's main practice is likely to support participation and improve service distribution.

Subsidies to target specialist outreach services into more remote locations: a national cross-sectional study.

Objective Targeting rural outreach services to areas of highest relative need is challenging because of the higher costs it imposes on health workers to travel longer distances. This paper studied whether subsidies have the potential to support the provision of specialist outreach services into more remote locations. Methods National data about subsidies for medical specialist outreach providers as part of the Wave 7 Medicine in Australia: Balancing Employment and Life (MABEL) Survey in 2014. Results Nearly half received subsidies: 19% (n=110) from a formal policy, namely the Australian Government Rural Health Outreach Fund (RHOF), and 27% (n=154) from other sources. Subsidised specialists travelled for longer and visited more remote locations relative to the non-subsidised group. In addition, compared with non-subsidised specialists, RHOF-subsidised specialists worked in priority areas and provided equally regular services they intended to continue, despite visiting more remote locations. Conclusion This suggests the RHOF, although limited to one in five specialist outreach providers, is important to increase targeted and stable outreach services in areas of highest relative need. Other subsidies also play a role in facilitating remote service distribution, but may need to be more structured to promote regular, sustained outreach practice. What is known about this topic? There are no studies describing subsidies for specialist doctors to undertake rural outreach work and whether subsidies, including formal and structured subsidies via the Australian Government RHOF, support targeted outreach services compared with no financial support. What does this paper add? Using national data from Australia, we describe subsidisation among specialist outreach providers and show that specialists subsidised via the RHOF or another source are more likely to provide remote outreach services. What are the implications for practitioners? Subsidised specialist outreach providers are more likely to provide remote outreach services. The RHOF, as a formally structured comprehensive subsidy, further targets the provision of priority services into such locations on a regular, ongoing basis.

The stability of rural outreach services: a national longitudinal study of specialist doctors.

OBJECTIVE: To explore the characteristics of specialists who provide ongoing rural outreach services and whether the nature of their service patterns contributes to ongoing outreach. DESIGN, PARTICIPANTS AND SETTING: Specialist doctors providing rural outreach in a large longitudinal survey of Australian doctors in 2008, together with new entrants to the survey in 2009, were followed up to 2011. MAIN OUTCOME MEASURES: Providing outreach services to the same rural town for at least 3 years. RESULTS: Of 953 specialists who initially provided rural outreach services, follow-up data were available for 848. Overall, 440 specialists (51.9%) provided ongoing outreach services. Multivariate analysis found that participation was associated with being male (odds ratio [OR], 1.82; 95% CI, 1.28-2.60), in mid-career (45-64 years old; OR, 1.44; 95% CI, 1.04-1.99), and working in mixed, mainly private practice (OR, 1.73; 95% CI, 1.18-2.53). Specialists working only privately were less likely to provide ongoing outreach (OR 0.51; 95% CI, 0.32-0.82), whereas metropolitan and rural-based specialists were equally likely to do so. Separate univariate analysis showed travelling further to remote towns had no effect on ongoing service provision. Outreach to smaller towns was associated with improved stability. CONCLUSIONS: Around half of specialists providing rural outreach services continue to visit the same town on an ongoing basis. More targeted outreach service strategies should account for career stage and practice conditions to help sustain access. Financial incentives may increase ongoing service provision by specialists only working privately. There is some indication that outreach services delivered to smaller communities are more stable.

The extra resource burden of in-hospital falls: a cost of falls study.

OBJECTIVE: To quantify the additional hospital length of stay (LOS) and costs associated with in-hospital falls and fall injuries in acute hospitals in Australia. DESIGN, SETTING AND PARTICIPANTS: A multisite prospective cohort study conducted during 2011-2013 in the control wards of a falls prevention trial (6-PACK). The trial included all admissions to 12 acute medical and surgical wards of six Australian hospitals. In-hospital falls data were collected from medical record reviews, daily verbal reports by ward nurse unit managers, and hospital incident reporting and administrative databases. Clinical costing data were linked for three of the six participating hospitals to calculate patient-level costs. OUTCOME MEASURES: Hospital LOS and costs associated with in-hospital falls and fall injuries for each patient admission. RESULTS: We found that 966 of a total of 27 026 hospital admissions (3.6%) involved at least one fall, and 313 (1.2%) at least one fall injury, a total of 1330 falls and 418 fall injuries. After adjustment for age, sex, cognitive impairment, admission type, comorbidity and clustering by hospital, patients who had an in-hospital fall had a mean increase in LOS of 8 days (95% CI, 5.8-10.4; P < 0.001) compared with non-fallers, and incurred mean additional hospital costs of $6669 (95% CI, $3888-$9450; P < 0.001). Patients with a fall-related injury had a mean increase in LOS of 4 days (95% CI, 1.8-6.6; P = 0.001) compared with those who fell without injury, and there was also a tendency to additional hospital costs (mean, $4727; 95% CI, -$568 to $10 022; P = 0.080). CONCLUSION: Patients who experience an in-hospital fall have significantly longer hospital stays and higher costs. Programs need to target the prevention of all falls, not just the reduction of fall-related injuries.

A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities.

BACKGROUND: residential aged care facility (RACF) resident numbers are increasing. Residents are frequently frail with substantial co-morbidity, functional and cognitive impairment with high susceptibility to acute illness. Despite living in facilities staffed by health professionals, a considerable proportion of residents are transferred to hospital for management of acute deteriorations in health. This model of emergency care may have unintended consequences for patients and the healthcare system. This review describes available evidence about the consequences of transfers from RACF to hospital. METHODS: a comprehensive search of the peer-reviewed literature using four electronic databases. Inclusion criteria were participants lived in nursing homes, care homes or long-term care, aged at least 65 years, and studies reported outcomes of acute ED transfer or hospital admission. Findings were synthesized and key factors identified. RESULTS: residents of RACF frequently presented severely unwell with multi-system disease. In-hospital complications included pressure ulcers and delirium, in 19 and 38% of residents, respectively; and up to 80% experienced potentially invasive interventions. Despite specialist emergency care, mortality was high with up to 34% dying in hospital. Furthermore, there was extensive use of healthcare resources with large proportions of residents undergoing emergency ambulance transport (up to 95%), and inpatient admission (up to 81%). CONCLUSIONS: acute emergency department (ED) transfer is a considerable burden for residents of RACF. From available evidence, it is not clear if benefits of in-hospital emergency care outweigh potential adverse complications of transfer. Future research is needed to better understand patient-centred outcomes of transfer and to explore alternative models of emergency healthcare.

The prehospital management of suspected spinal cord injury: an update.

INTRODUCTION: Spinal cord injury (SCI) is a serious condition that may lead to long-term disabilities placing financial and social burden on patients and their families, as well as their communities. Spinal immobilization has been considered the standard prehospital care for suspected SCI patients. However, there is a lack of consensus on its beneficial impact on patients' outcome. OBJECTIVE: This paper reviews the current literature on the epidemiology of traumatic SCI and the practice of prehospital spinal immobilization. DESIGN: A search of literature was undertaken utilizing the online databases Ovid Medline, PubMed, CINAHL, and the Cochrane Library. The search included English language publications from January 2000 through November 2012. RESULTS: The reported annual incidence of SCI ranges from 12.7 to 52.2 per 1 million and occurs more commonly among males than females. Motor vehicle collisions (MVCs) are the major reported causes of traumatic SCI among young and middle-aged patients, and falls are the major reported causes among patients older than 55. There is little evidence regarding the relationship between prehospital spinal immobilization and patient neurological outcomes. However, early patient transfer (8-24 hours) to spinal care units and effective resuscitation have been demonstrated to lead to better neurological outcomes. CONCLUSION: This review reaffirms the need for further research to validate the advantages, disadvantages, and the effects of spinal immobilization on patients' neurological outcomes.

A prospective multicentre study of barriers to discharge from inpatient rehabilitation.

OBJECTIVES: To assess the prevalence of and reasons for barriers to discharge from inpatient rehabilitation, to measure the resulting additional days in hospital, and to determine if these were predicted by key demographic or clinical variables. DESIGN, SETTING AND PARTICIPANTS: Prospective open cohort study of 360 patients admitted into two inpatient rehabilitation units in Melbourne over an 8-02 and a 10-02 period in 2008. MAIN OUTCOME MEASURES: Occurrence of discharge barriers, their causes and the duration of unnecessary hospitalisation. RESULTS: There were 360 patients in the study sample, 186 were female (51.7%), and mean age was 58.4 years. Fifty-nine (16.4%) patients had a discharge barrier. The most frequent causes of discharge barriers were patients being non-weight bearing after lower limb fracture, family deliberations about discharge planning, waiting for home modifications and waiting for accommodation. Patients with acquired brain damage and lower limb fracture were the impairment groups most likely to experience a discharge barrier. Over the study period, 21.0% (3152/14 976) of all bed-days were occupied by patients deemed to have a discharge barrier. Regression analysis showed that age, sex, impairment group and dependency level on admission all influenced the occurrence of a discharge barrier. Although regression analysis showed that dependency on admission and age group were significant predictors of additional days in hospital resulting from discharge barriers (P = 0.006), these variables explained only 11% of the additional bed-days. CONCLUSION: Barriers to discharge from inpatient rehabilitation are common and substantial, and they represent an important opportunity for improvement.

Defining barriers to discharge from inpatient rehabilitation, classifying their causes, and proposed performance indicators for rehabilitation patient flow.

There is little research literature on patient flow in rehabilitation. Accepted definitions of barriers to discharge and agreed performance measures are needed to support research and understanding of this topic. The potential of improved patient flow in rehabilitation to assist relieving demand pressures in acute hospitals underscores its importance. This study develops a definition of barriers to discharge from postacute care and classifies their causes using a multiphased iterative consultation and feedback process involving physiatrists, aged-care physicians, and senior nursing and allied health clinicians. Key performance indicators (KPIs) for postacute patient flow are then proposed, the development of which were informed by the available literature and a survey (n=101) of physiatrists, aged-care physicians, and hospital managers with responsibility for patient flow who were questioned about the use of relevant KPIs in this setting. Most (>70%) respondents believed that using KPIs (eg, waiting time from acceptance by postacute care and ready for transfer until admission, percentage of postacute bed days occupied by inpatients with a discharge barrier) to measure aspects of patient flow could improve processes, but few reported collecting this information (45% admission KPIs, 19% discharge KPIs). By using the definition and classification of discharge barriers prospectively to document and address barriers, in conjunction with appropriate KPIs, postacute patient flow and the efficiency of hospital resource utilization can potentially be improved. Our commentary aims to stimulate interest among others to develop a more robust evidence base for improved flow through postacute care.

Epidemiologic merit of obese-years, the combination of degree and duration of obesity.

This study aims to test the effect of combining the degree and the duration of obesity into a single variable-obese-years-and to examine whether obese-years is a better predictor of the risk of diabetes than simply body mass index (BMI) or duration of obesity. Of the original cohort of the Framingham Heart Study, 5,036 participants were followed up every 2 years for up to 48 years (from 1948). The variable, obese-years, was defined by multiplying for each participant the number of BMI units above 30 kg/m(2) by the number of years lived at that BMI. Associations with diabetes were analyzed by using time-dependent Cox proportional hazards regression models adjusted for potential confounders. The incidence of type-2 diabetes increased as the number of obese-years increased, with adjusted hazard ratios of 1.07 (95% confidence interval: 1.06, 1.09) per additional 10 obese-years. The dose-response relation between diabetes incidence and obese-years varied by sex and smoking status. The Akaike Information Criterion was lowest in the model containing obese-years compared with models containing either the degree or duration of obesity alone. A construct of obese-years is strongly associated with risk of diabetes and could be a better indicator of the health risks associated with increasing body weight than BMI or duration of obesity alone.

Demand at the emergency department front door: 10-year trends in presentations.

OBJECTIVES: To measure the increase in volume and age-specific rates of presentations to public hospital emergency departments (EDs), as well as any changes in ED length of stay (LOS); and to describe trends in ED utilisation. DESIGN, PATIENTS AND SETTING: Population-based retrospective analysis of Department of Health public hospital ED data for metropolitan Melbourne for 1999-00 to 2008-09. MAIN OUTCOME MEASURES: Presentation numbers; presentation rates per 1000 person-years; ED LOS. RESULTS: ED presentations increased from 550,662 in 1999-00 to 853,940 in 2008-09. This corresponded to a 32% rise in rate of presentation (95% CI, 29%-35%), an average annual increase of 3.6% (95% CI, 3.4%-3.8%) after adjustment for population changes. Almost 40% of all patients remained in the ED for ≥4 hours in 2008-09, with LOS increasing over time for patients who were more acutely unwell. The likelihood of presentation rose with increasing age, with people aged≥85 years being 3.9 times as likely to present as those aged 35-59 years (95% CI, 3.8-4.0). The volume of older people presenting more than doubled over the decade. They were more likely to arrive by emergency ambulance and were more acutely unwell than 35-59 year olds, with 75% having an LOS≥4 hours and 61% requiring admission in 2008-09. CONCLUSION: The rise in presentation numbers and presentation rates per 1000 person-years over 10 years was beyond that expected from demographic changes. Current models of emergency and primary care are failing to meet community needs at times of acute illness. Given these trends, the proposed 4-hour targets in 2012 may be unachievable unless there is significant redesign of the whole system.

A review of hospital characteristics associated with improved performance.

PURPOSE: The objective of this review was to critically appraise the literature relating to associations between high-level structural and operational hospital characteristics and improved performance. DATA SOURCES: The Cochrane Library, MEDLINE (Ovid), CINAHL, proQuest and PsychINFO were searched for articles published between January 1996 and May 2010. Reference lists of included articles were reviewed and key journals were hand searched for relevant articles. STUDY SELECTION: and data extraction Studies were included if they were systematic reviews or meta-analyses, randomized controlled trials, controlled before and after studies or observational studies (cohort and cross-sectional) that were multicentre, comparative performance studies. Two reviewers independently extracted data, assigned grades of evidence according to the Australian National Health and Medical Research Council guidelines and critically appraised the included articles. Data synthesis Fifty-seven studies were reported within 12 systematic reviews and 47 observational articles. There was heterogeneity in use and definition of performance outcomes. Hospital characteristics investigated were environment (incentives, market characteristics), structure (network membership, ownership, teaching status, geographical setting, service size) and operational design (innovativeness, leadership, organizational culture, public reporting and patient safety practices, information technology systems and decision support, service activity and planning, workforce design, staff training and education). The strongest evidence for an association with overall performance was identified for computerized physician order entry systems. Some evidence supported the associations with workforce design, use of financial incentives, nursing leadership and hospital volume. CONCLUSION: There is limited, mainly low-quality evidence, supporting the associations between hospital characteristics and healthcare performance. Further characteristic-specific systematic reviews are indicated.

Inpatient subacute care in Australia: perceptions of admission and discharge barriers.

OBJECTIVE: To determine perceptions of barriers to admission to subacute care from acute hospital care, and barriers to subsequent discharge from subacute care. DESIGN, PARTICIPANTS AND SETTING: Web-based survey of key stakeholders using Likert scales and closed questions. Prompts were emailed repeatedly to potential participants in Australia between 15 May and 24 July 2009. Participants were physicians working in inpatient rehabilitation medicine and aged care units, as well as senior hospital managers with responsibility for patient flow. MAIN OUTCOME MEASURES: Perceived admission and discharge barriers in subacute care. RESULTS: Half of the 101 respondents reported barriers to admission to subacute hospitals as moderate, severe or extreme, and 81% reported a similar grading of severity for barriers to discharge. There was no relationship between these perceptions and whether respondents worked only in the public hospital system (barriers to access: χ² = 0.02 [df = 1; P = 1.0]; and barriers to discharge: χ² = 0.0 [df = 1; P = 1.0]). The most commonly reported barriers to admission were: availability of beds (61% of respondents); physical, environmental and equipment inadequacies (62% of respondents); and allied health or nursing staff issues (55% of respondents). The most commonly reported barriers to discharge included: waiting for a more appropriate setting of care (76% of respondents) and funding for home modifications, equipment or carers (55% of respondents). There was no relationship between respondents' position and their reporting of various admission (χ² = 6.2; df = 8; P = 0.6) or discharge barriers (χ² = 13.8; df = 12; P = 0.3). CONCLUSION: There is a strong perception among key stakeholders in subacute care that there are major barriers to patient admission and discharge. Redistributing proposed funding for inpatient subacute beds to measures for overcoming these barriers is likely to improve patient flow though the whole hospital system.

The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015.

OBJECTIVE: To measure the growth in emergency ambulance use across metropolitan Melbourne since 1995, to measure the impact of population growth and ageing on these services, and to forecast demand for these services in 2015. DESIGN AND SETTING: A population-based retrospective analysis of Ambulance Victoria's metropolitan emergency ambulance transportation data for the period from financial year 1994-95 to 2007-08, and modelling of demand in the financial year 2014-15. MAIN OUTCOME MEASURES: Numbers and rates of emergency ambulance transportations. RESULTS: The crude annual rate of emergency transportations across all age groups increased from 32 per 1000 people in 1994-95 to 58 per 1000 people in 2007-08. The rate of transportation for all ages increased by 75% (95% CI, 62%-89%) over the 14-year study period, representing an average annual growth rate of 4.8% (95% CI, 4.3%-5.3%) beyond that explained by demographic changes. Patients aged ≥ 85 years were eight times (incident rate ratio, 7.9 [95% CI, 7.6-8.3]) as likely to be transported than those aged 45-69 years over this period. Forecast models suggest that the number of transportations will increase by 46%-69% between 2007-08 and 2014-15, disproportionately driven by increasing usage by patients aged ≥ 85 years. CONCLUSIONS: These findings confirm a dramatic rise in emergency transportations over the study period, beyond that expected from demographic changes. Rates increased across all age groups, but more so in older patients. In the future, such acceleration is likely to have major effects on ambulance services and acute hospital capacity. This calls for further investigation of underlying causes and alternative models of care.

Systematic review of trends in emergency department attendances: an Australian perspective.

Emergency departments (EDs) in many developed countries are experiencing increasing pressure due to rising numbers of patient presentations and emergency admissions. Reported increases range up to 7% annually. Together with limited inpatient bed capacity, this contributes to prolonged lengths of stay in the ED; disrupting timely access to urgent care, posing a threat to patient safety. The aim of this review is to summarise the findings of studies that have investigated the extent of and the reasons for increasing emergency presentations. To do this, a systematic review and synthesis of published and unpublished reports describing trends and underlying drivers associated with the increase in ED presentations in developed countries was conducted. Most published studies provided evidence of increasing ED attendances within developed countries. A series of inter-related factors have been proposed to explain the increase in emergency demand. These include changes in demography and in the organisation and delivery of healthcare services, as well as improved health awareness and community expectations arising from health promotion campaigns. The factors associated with increasing ED presentations are complex and inter-related and include rising community expectations regarding access to emergency care in acute hospitals. A systematic investigation of the demographic, socioeconomic and health-related factors highlighted by this review is recommended. This would facilitate untangling the dynamics of the increase in emergency demand.

Increasing utilisation of emergency ambulances.

BACKGROUND: Increased ambulance utilisation is closely linked with Emergency Department (ED) attendances. Pressures on hospital systems are widely acknowledged with ED overcrowding reported regularly in the media and peer-reviewed literature. Strains on ambulance services are less well-documented or studied. AIMS: To review the literature to determine the trends in utilisation of emergency ambulances throughout the developed world and to discuss the major underlying drivers perceived as contributing to this increase. METHOD: A search of online databases, search engines, peer-reviewed journals and audit reports was undertaken. FINDINGS: Ambulance utilisation has increased in many developed countries over the past 20 years. Annual growth rates throughout Australia and the United Kingdom are similar. Population ageing, changes in social support, accessibility and pricing, and increasing community health awareness have been proposed as associated factors. As the extent of their contribution has not yet been established these factors were reviewed. CONCLUSION: The continued rise in utilisation of emergency ambulances is placing increasing demands on ambulance services and the wider health system, potentially compromising access, quality, safety and outcomes. A variety of factors may contribute to this increase and targeted strategies to reduce utilisation will require an accurate identification of the major drivers of demand.

Applying composite performance measures to trauma care.

BACKGROUND: To investigate the association between a number of hospital level composite index methodologies developed from trauma indicators with inhospital mortality. METHODS: Data from January 2001 to December 2006 were extracted from the Victorian State Trauma Registry (Australia) and the Trauma Audit and Research Network (United Kingdom). Three composite methods were explored, including two denominator-based weight approaches and a factor analysis technique. The association between the composite measures and the count of inhospital mortality was investigated using Poisson regression models adjusting for expected deaths per hospital using the Trauma Injury Severity Score methodology. RESULTS: Composite scores were calculated per hospital, per year. The composite score was entered in statistical models as a raw score, and the mortality difference across the central 50% of the composite index was ascertained. In total, 9,218 patients were included and were distributed across 14 hospitals. Composite scores demonstrated an inverse relationship with risk-adjusted inhospital mortality. From the 25th to the 75th percentile of each composite, mortality decreased by 11.99%, 13.58%, and 16.13% (p < 0.05). CONCLUSION: Trauma composite indices demonstrate construct validity when used as measures of hospital level process and represent potentially useful methods of analyzing and reporting quality indicators.