A landscape assessment of the use of patient reported outcome measures in research, quality improvement and clinical care across a healthcare organisation.

BACKGROUND: Patient reported outcome measures (PROMs) can be used by healthcare organisations to inform improvements in service delivery. However, routine collection of PROMs is difficult to achieve across an entire healthcare organisation. An understanding of the use of PROMs within an organisation can provide valuable insights on the purpose, scope and practical considerations of PROMs collection, which can inform implementation of PROMs. METHODS: We used multiple research methods to assess the use of PROMs in research projects, data registries and clinical care across a healthcare organisation from January 2014 to April 2021. The methods included an audit of ethics applications approved by the organisation's human research ethics committee and registries which the health organisation had contributed data to; a literature review of peer-reviewed journal articles reporting on research projects conducted at the organisation; and a survey of health professionals use of PROMs in research projects, data registries and clinical care. The scope of PROMs was determined by classifying PROMs as either 'specific' to a particular disease and/or condition, or as a 'generic' measure with further classification based on the health domains they measured, using the World Health Organization International Classification Framework. Practical considerations included mode and timing of PROMs administration. Data were described using frequency and proportion. RESULTS: PROMs were used by 22% of research projects (n = 144/666), 68% of data registries (n = 13/19), and 76% of clinical specialties in their clinical care (n = 16/21). Disease specific PROMs were most commonly used: 83% of research projects (n = 130/144), 69% of clinical registries (n = 9/13), and 75% of clinical specialties (n = 12/16). Greater than 80% of research projects, clinical registries and clinical specialties measured health domains relating to both body impairments and participation in daily life activities. The most commonly used generic PROM was the EQ-5D (research projects n = 56/144, 39%; data registries n = 5/13, 38%; clinical specialties n = 4/16, 25%). PROMs used in clinical care were mostly paper-based (n = 47/55, 85%). CONCLUSIONS: We have elicited information on the use of PROMs to inform a health organisation wide implementation strategy. Future work will determine clinician and patient acceptability of the EQ-5D, and co-design a system for the collection of PROMs.

Return on investment of a model of access combining triage with initial management: an economic analysis.

OBJECTIVES: Timely access to outpatient services is a major issue for public health systems. To address this issue, we aimed to establish the return on investment to the health system of the implementation of an alternative model for access and triage (Specific Timely Appointments for Triage: STAT) compared with a traditional waitlist model. DESIGN: Using a prospective pre-post design, an economic analysis was completed comparing the health system costs for participants who were referred for community outpatient services post-implementation of STAT with a traditional waitlist comparison group. SETTING: Eight community outpatient services of a health network in Melbourne, Australia. PARTICIPANTS: Adults and children referred to community outpatient services. INTERVENTIONS: STAT combined targeted activities to reduce the existing waiting list and direct booking of patients into protected assessment appointments. STAT was compared with usual care, in which new patients were placed on a waiting list and offered appointments as space became available. OUTCOMES: Health system costs included STAT implementation costs, outpatient health service use, emergency department presentations and hospital admissions 3 months before and after initial outpatient appointment. Waiting time was the primary outcome. Incremental cost-effectiveness ratios (ICERs) were estimated from the health system perspective. RESULTS: Data from 557 participants showed a 16.9 days or 29% (p<0.001) reduction in waiting time for first appointment with STAT compared with traditional waitlist. The ICER showed a cost of $A10 (95% CI -19 to 39) per day reduction in waiting time with STAT compared with traditional waitlist. Modelling showed the cost reduced to $A4 (95% CI -25 to 32) per day of reduction in waiting, if reduction in waiting times is sustained for 12 months. CONCLUSIONS: There was a significant reduction in waiting time with the introduction of STAT at minimal cost to the health system. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12615001016527).

Motivational interviewing with community-dwelling older adults after hip fracture (MIHip): protocol for a randomised controlled trial.

INTRODUCTION: Community-dwelling people recovering from hip fracture have the physical capacity to walk in their community but lack the confidence to do so. The primary aim of this trial is to determine whether motivational interviewing increases time spent walking at 12 months in community-dwelling people after hip fracture compared with an attention placebo control group. Secondary aims are to evaluate cost effectiveness, patient and health service outcomes and to complete a process evaluation. METHODS AND ANALYSIS: An assessor-blinded parallel group randomised controlled design with embedded health economic evaluation and process evaluation will compare the effects of n=270 participants randomly allocated to an experimental group (motivational interviewing) or a control group (dietary advice). For inclusion, participants are aged ≥65 years, living at home independently within 6 months of discharge from hospital after hip fracture and able to walk independently and communicate with conversational English. Key exclusion criteria are severe depression or anxiety, impaired intellectual functioning and being medically unstable to walk. Participants allocated to the experimental group will receive 10 (8 weekly and 2 booster) telephone-based sessions of motivational interviewing to increase walking over 16 weeks. Participants allocated to the control group will receive an equivalent dose of telephone-based dietary advice. The primary outcome is daily time spent walking over 7 days assessed at weeks 0, 9, 26 and 52. Secondary outcomes include measures of psychological-related function, mobility-related function, community participation, health-related quality of life and falls. Health service utilisation and associated costs will be assessed. Process evaluation will assess the fidelity of the motivational interviewing intervention and explore contextual factors through semistructured interviews. ETHICS AND DISSEMINATION: Ethical approval obtained from Eastern Health (E19-002), Peninsula Health (50261/EH-2019), Alfred Health (617/20) and La Trobe University (E19/002/50261). The findings will be disseminated in peer-reviewed journals, conference presentations and public seminars. TRIAL REGISTRATION NUMBER: ACTRN12619000936123.

Quantifying the economic benefit of the personal alarm and emergency response system in Australia: a cost analysis of the reduction in ambulance attendances.

Objectives MePACS is a triage and support-based personal alarm emergency response system designed to assist older and/or disabled people to live safely in their homes. The aim of this study was to estimate avoidable ambulance attendances and transports to emergency departments and quantify the cost savings attributed to MePACS compared with a comparison cohort without a personal alarm system. Methods Alarm activation and demographic data for clients registered in the program from June 2016 to May 2017 and funded through the Personal Alert Victoria program were extracted from routinely collected MePACS electronic data. Information on alarm use, event outcomes and ambulance attendances was extracted. Using published Ambulance Victoria data, a comparison cohort was simulated to model the experience of a similar cohort without access to a personal alarm system who experienced a health emergency and called Australia's emergency call service number. The incremental management cost, incorporating the operation cost of MePACS and ambulance fees, was calculated to compare the potential cost savings of MePACS with the comparison cohort. Results Among 18421 eligible clients, there were 7856 emergency alarm activations due to falls or medical events from 4275 clients (79.5% female; 81.1% aged >75 years; 91.8% living alone). MePACS resulted in approximately one-third of ambulance attendances being avoided. Potential annual cost savings of A$1414732.8 (A$76.8 per person per year; 95% confidence interval A$60.0-93.6 per person per year; P<0.001) were attributed to avoidable ambulance utilisations for 18421 MePACS clients. Conclusion Triage-based personal alarm systems, such as MePACS, provide a cost-saving strategy because of fewer ambulance attendances and transports to emergency departments for older and/or disabled people living in the community. What is known about the topic? Personal alarm systems, either a safety alarm, a panic alarm or a medical alarm, have been widely used to support older people and at-risk groups to live independently. The health effects of personal alarm systems are well documented. There is limited information published on the potential economic benefits of these interventions. What does this paper add? We identified the potential economic benefits associated with the MePACS triage-based personal alarm system operating within Victoria, Australia. Personal alarm systems that are triage based and use the support of family members and carers may provide financial benefits not provided by alarm systems that do not provide this type of service. What are the implications for practitioners? The management of older people and at-risk groups living alone is a health care priority. Alternative models to calling emergency services, such as triage-based personal emergency response systems, may provide a low-cost, effective approach.

Sustainable waiting time reductions after introducing the STAT model for access and triage: 12-month follow up of a stepped wedge cluster randomised controlled trial.

BACKGROUND: Timely access is a challenge for providers of outpatient and community-based health services, as seen by the often lengthy waiting lists to manage demand. The Specific Timely Appointments for Triage (STAT) model, an alternative approach for managing access and triage, reduced waiting time by 34% in a stepped wedge cluster randomised controlled trial involving 8 services and more than 3000 participants. Follow up periods ranged from 3 to 10 months across the participating services in accordance with the stepped wedge design. This study aimed to determine whether outcomes were sustained for a full 12 months after implementation of the STAT model at each site. METHODS: Routinely collected service data were obtained for a total of 12 months following implementation of the STAT model at each of the 8 services that participated in a stepped wedge cluster randomised controlled trial. The primary outcome was time to first appointment. Secondary outcomes included non-attendance rates, time to second appointment and service use over 12 weeks. Outcomes were compared to pre-intervention data from the original trial, modelled using generalised linear mixed effects models accounting for clustering of sites. RESULTS: A 29% reduction in waiting time could be attributed to STAT over 12 months, compared to 34% in the original trial. A reduction in variability in waiting time was sustained. There were no significant changes in time to second appointment or in the number of missed appointments in the extended follow up period. CONCLUSIONS: STAT is an effective strategy for reducing waiting time in community-based outpatient services. At 12 months, small reductions in the overall effect are apparent, but reductions in variability are sustained, suggesting that people who previously waited the longest benefit most from the STAT model. TRIAL REGISTRATION: This is a 12-month follow up of a stepped wedge cluster randomised controlled trial that was registered with the Australia and New Zealand Clinical Trials Registry ( ACTRN12615001016527 ).

Are wait lists inevitable in subacute ambulatory and community health services? A qualitative analysis.

Objectives Wait lists are common in ambulatory and community-based services. The aim of the present study was to explore managers' perceptions of factors that contribute to wait times. Methods A qualitative study was conducted using semi-structured interviews with managers and team leaders of ambulatory and community health services within a large health network. Interviews were transcribed and coded, and the codes were then grouped into themes and subthemes. Results Representatives from 26 services participated in the project. Four major themes were identified. Three themes related to reasons and factors contributing to increased wait time for services (inefficient intake and scheduling processes; service disruptions due to human resource issues; and high service demand). A fourth theme related to staff attitudes towards wait times and acceptance and acknowledgement of wait lists. Conclusions Service providers perceive high demand to be a key driver of wait times, but a range of other factors also contributes and may represent opportunities for improving access to care. These other factors include improving process efficiencies, greater consistency of service delivery through more efficient management of human resources and shifting to more consumer-centred approaches in measuring wait times in order to drive improvements in patient flow. What is known about the topic? Wait times are common in out-patient and ambulatory services. These services experience high demand, which is likely to continue to grow as health service delivery shifts from hospital to community settings. What does this paper add? Although demand is an important driver of wait times, there are other modifiable factors that also contribute, including process inefficiencies and service disruption related to human resource issues. An underlying staff attitude of acceptance of wait times appears to be an additional barrier to improving access. What are the implications for practitioners? The findings of the present study suggest that there are opportunities for improving access to ambulatory and community health services through more efficient use of existing resources. However, a more consumer-focused approach regarding acceptability of wait times is needed to help drive change.

Physiotherapy departments in Australian tertiary hospitals regularly participate in and disseminate research results despite a lack of allocated staff: a prospective cross-sectional survey.

OBJECTIVES: To establish the level of research activity in physiotherapy departments of Australian tertiary hospitals. DESIGN: Prospective cross-sectional survey. PARTICIPANTS: Physiotherapy managers from 37 principal referral hospitals and specialist women's and children's hospitals as identified from the Australian Institute of Health and Welfare (2011). MAIN OUTCOME MEASURES: A purpose-designed predominantly open-response questionnaire investigating site demographics, research activity and research support was developed, piloted and administered. RESULTS: Thirty-seven surveys were completed (54% response rate). Median [IQR] respondent equivalent full-time staffing was 23.8 (19-39). Respondents represented a median [IQR] 6.5 (3-20) publication output in the past 2 years. Twelve respondents (32%) reported that staff had completed a doctorate in the past 5 years and 49% of respondents reported no staff had completed higher degrees. A total of 71 grants had been received and 73% of respondents indicated they had no allocated staffing for research activity. The most common indicators of research culture were organization-led research dissemination events and research training (i.e. manager attending research events and celebrating research achievements). CONCLUSIONS: This is the first study to report on research activity in hospital-based Australian physiotherapy departments. Few sites allocate staff to conduct or support research. Despite this, physiotherapy departments regularly publish and present research results. Future studies could investigate how hospital-based physiotherapy departments can optimize research culture and output.

A nonstationary Markov transition model for computing the relative risk of dementia before death.

This paper investigates the long-term behavior of the k-step transition probability matrix for a nonstationary discrete-time Markov chain in the context of modeling transitions from intact cognition to dementia with mild cognitive impairment and global impairment as intervening cognitive states. The authors derive formulas for the following absorption statistics: (1) the relative risk of absorption between competing absorbing states and (2) the mean and variance of the number of visits among the transient states before absorption. As absorption is not guaranteed, sufficient conditions are discussed to ensure that the substochastic matrix associated with transitions among transient states converges to zero in limit. Results are illustrated with an application to the Nun Study, a cohort of 678 participants, 75-107 years of age, followed longitudinally with up to 10 cognitive assessments over a 15-year period.

Transitions to mild cognitive impairments, dementia, and death: findings from the Nun Study.

The potential of early interventions for dementia has increased interest in cognitive impairments less severe than dementia. However, predictors of the trajectory from intact cognition to dementia have not yet been clearly identified. The purpose of this study was to determine whether known risk factors for dementia increased the risk of mild cognitive impairments or progression from mild cognitive impairments to dementia. A polytomous logistic regression model was used, with parameters governing transitions within transient states (intact cognition, mild cognitive impairments, global impairment) estimated separately from parameters governing the transition from transient to absorbing state (dementia or death). Analyses were based on seven annual examinations (1991-2002) of 470 Nun Study participants aged > or = 75 years at baseline and living in the United States. Odds of developing dementia increased with age primarily for those with low educational levels. In these women, presence of an apolipoprotein E gene *E4 allele increased the odds more than fourfold by age 95 years. Age, education, and the apolipoprotein E gene were all significantly associated with mild cognitive impairments. Only age, however, was associated with progression to dementia. Thus, risk factors for dementia may operate primarily by predisposing individuals to develop mild cognitive impairments; subsequent progression to dementia then depends on only time and competing mortality.