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.

Development and internal validation of a dynamic fall risk prediction and monitoring tool in aged care using routinely collected electronic health data: a landmarking approach.

OBJECTIVES: Falls pose a significant challenge in residential aged care facilities (RACFs). Existing falls prediction tools perform poorly and fail to capture evolving risk factors. We aimed to develop and internally validate dynamic fall risk prediction models and create point-based scoring systems for residents with and without dementia. MATERIALS AND METHODS: A longitudinal cohort study using electronic data from 27 RACFs in Sydney, Australia. The study included 5492 permanent residents, with a 70%-30% split for training and validation. The outcome measure was the incidence of falls. We tracked residents for 60 months, using monthly landmarks with 1-month prediction windows. We employed landmarking dynamic prediction for model development, a time-dependent area under receiver operating characteristics curve (AUROCC) for model evaluations, and a regression coefficient approach to create point-based scoring systems. RESULTS: The model identified 15 independent predictors of falls in dementia and 12 in nondementia cohorts. Falls history was the key predictor of subsequent falls in both dementia (HR 4.75, 95% CI, 4.45-5.06) and nondementia cohorts (HR 4.20, 95% CI, 3.87-4.57). The AUROCC across landmarks ranged from 0.67 to 0.87 for dementia and from 0.66 to 0.86 for nondementia cohorts but generally remained between 0.75 and 0.85 in both cohorts. The total point risk score ranged from -2 to 57 for dementia and 0 to 52 for nondementia cohorts. DISCUSSION: Our novel risk prediction models and scoring systems provide timely person-centered information for continuous monitoring of fall risk in RACFs. CONCLUSION: Embedding these tools within electronic health records could facilitate the implementation of targeted proactive interventions to prevent falls.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability.

BACKGROUND: This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change. METHODS: We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. RESULTS: CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. CONCLUSIONS: A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

The Economics of Medication Safety: A Cost-Benefits Analysis Framework for Evaluating an Electronic Medication System.

Medication prescribing in paediatrics is complex and compounded by the need to provide age and weight related doses, and errors continue to be problematic. Electronic medication systems (EMS) can reduce errors through dosing calculators and computerised decision support. However, evidence on costs and benefits of these systems is limited, particularly in paediatric hospitals. This paper presents the development of a cost-benefit analysis (CBA) framework to assess the impact of an EMS implementation in a paediatric tertiary hospital. An innovative component of the framework is the incorporation of the impact of the effects of the EMS for both the health system as well as for patients and their wider family networks, allowing a net social benefit assessment. We describe the impact of non-clinical out-of-pocket costs of admission and use discrete choice experiments to measure both medication related harm and the importance of medication safety to families and members of the community.

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.

Allied health service delivery in residential aged care and the impact of the coronavirus (COVID-19) pandemic: a survey of the allied health workforce.

Objectives Industry reports suggest that routine and essential care in Australian residential aged care (RAC), including allied health (AH) services, were disrupted during the coronavirus diseas 2019 (COVID-19) pandemic. This study aimed to explore whether AH services in RAC were paused during the pandemic, factors associated with a pause in care delivery, and qualitative details on how COVID-19 impacted AH service delivery. Methods A 26-question survey was distributed via social media, health service providers, and AH networks between February and April 2022. Participation was restricted to AH professionals and assistants with experience in RAC during the pandemic. A mix of closed and open-ended response questions was used to collect demographic data and experiences of delivering care during the pandemic. Quantitative responses were analysed with descriptive statistics and a probit model. Content analysis was performed on open-ended questions. Results One hundred and four AH professionals and assistants responded to the survey. Fifty-five percent of participants (n = 51) were contractually or casually employed. AH services were negatively impacted by the pandemic with 52% of respondents experiencing a pause in service delivery and 78% reporting poorer AH care quality. In a probit model, contracted/casually employed respondents were more likely to experience a pause in care delivery (1.03, P < 0.05) compared to permanently employed AH professionals. Conclusion Insecure work arrangements may have exacerbated inconsistent care during the pandemic (impacting residents) and may have negative implications on the RAC AH workforce. In the future, an AH inclusive workforce policy including data collection and research is required to monitor and plan the RAC workforce.

An assessment of organisational culture in Australian hospitals using employee online reviews.

The aim of this study was to analyse the content of online reviews posted by hospital employees on job websites for themes of organisational culture. 103 anonymous online reviews across three job websites, posted by hospital employees of four hospitals within an Australian health network were extracted. Reviews had been posted across a period of six years, from 2014 to early 2020. Sentiment rating based on user-allotted ratings on the selected websites was calculated. The sentiment score was validated against the textual content of the review to confirm employee recommendation and sentiment. Sentiment was coded as neutral, positive, or negative. Significant keywords, associations, and usage within the context of identified sentiment were deductively coded and clustered manually against eight pre-determined safety culture themes. These themes were derived from the most used assessment tools for self-reported measures of occupational health and safety, and safety culture in healthcare. Workers across clinical roles (n = 49) and non-clinical roles (n = 50) were evenly represented in the dataset. 35.9% of commenters (n = 37) reported their length of employment in the hospitals that they reviewed. Most online employee reviews addressed broad themes related to perceptions of management (n = 98), safety climate (n = 97), teamwork climate (n = 91) and working conditions (n = 98). A significant set of reviews addressed themes related to job satisfaction (n = 49) and learning, training, and development (n = 41). 72.8% of online reviews (n = 75) expressed positive sentiment towards their employer. Reviews expressing negative sentiment were largely posted by former employees and indicated areas of discontent that reflected organisational and systemic factors. Online employee reviews posted by hospital workers on job sites provide valuable insights into healthcare organisational culture. Therefore, employee online reviews could be used as a supplementary source of data to inform organisational employee engagement initiatives.

The use and predictive performance of the Peninsula Health Falls Risk Assessment Tool (PH-FRAT) in 25 residential aged care facilities: a retrospective cohort study using routinely collected data.

BACKGROUND: The Peninsula Health Falls Risk Assessment Tool (PH-FRAT) is a validated and widely applied tool in residential aged care facilities (RACFs) in Australia. However, research regarding its use and predictive performance is limited. This study aimed to determine the use and performance of PH-FRAT in predicting falls in RACF residents. METHODS: A retrospective cohort study using routinely-collected data from 25 RACFs in metropolitan Sydney, Australia from Jul 2014-Dec 2019. A total of 5888 residents aged ≥65 years who were assessed at least once using the PH-FRAT were included in the study. The PH-FRAT risk score ranges from 5 to 20 with a score > 14 indicating fallers and ≤ 14 non-fallers. The predictive performance of PH-FRAT was determined using metrics including area under receiver operating characteristics curve (AUROC), sensitivity, specificity, sensitivityEvent Rate(ER) and specificityER. RESULTS: A total of 27,696 falls were reported over 3,689,561 resident days (a crude incident rate of 7.5 falls /1000 resident days). A total of 38,931 PH-FRAT assessments were conducted with a median of 4 assessments per resident, a median of 43.8 days between assessments, and an overall median fall risk score of 14. Residents with multiple assessments had increased risk scores over time. The baseline PH-FRAT demonstrated a low AUROC of 0.57, sensitivity of 26.0% (sensitivityER 33.6%) and specificity of 88.8% (specificityER 82.0%). The follow-up PH-FRAT assessments increased sensitivityER values although the specificityER decreased. The performance of PH-FRAT improved using a lower risk score cut-off of 10 with AUROC of 0.61, sensitivity of 67.5% (sensitivityER 74.4%) and specificity of 55.2% (specificityER 45.6%). CONCLUSIONS: Although PH-FRAT is frequently used in RACFs, it demonstrated poor predictive performance raising concerns about its value. Introducing a lower PH-FRAT cut-off score of 10 marginally enhanced its predictive performance. Future research should focus on understanding the feasibility and accuracy of dynamic fall risk predictive tools, which may serve to better identify residents at risk of falls.

Impact of Electronic Medication Management on the Physical Location of Work in a Paediatric Setting.

Electronic medication management (eMM) systems can have a significant impact on efficiency and safety. There is limited evidence on the effects of eMM implementation on the physical location of work. The objective of this study was to evaluate the impact of eMM and associated hardware implementation on the location of tasks performed by doctors and nurses. 41.5 hours of observation were conducted in the oncology ward of a paediatric hospital. Tasks, locations and resources used were recorded pre and post eMM implementation. Results showed that a wider variety of locations were used to conduct tasks following eMM implementation. Post-eMM, more tasks were performed in the hallway, where medication trolleys with attached laptops were situated, and in patient rooms where additional computers were installed, providing more opportunities for patient/carer and clinician interaction. The findings from this study reveal the impact that computer placement has on the location of work for doctors and nurses, and the importance of planning hardware placement for eMM implementation.

Co-designing a dashboard of predictive analytics and decision support to drive care quality and client outcomes in aged care: a mixed-method study protocol.

INTRODUCTION: There is a clear need for improved care quality and quality monitoring in aged care. Aged care providers collect an abundance of data, yet rarely are these data integrated and transformed in real-time into actionable information to support evidence-based care, nor are they shared with older people and informal caregivers. This protocol describes the co-design and testing of a dashboard in residential aged care facilities (nursing or care homes) and community-based aged care settings (formal care provided at home or in the community). The dashboard will comprise integrated data to provide an 'at-a-glance' overview of aged care clients, indicators to identify clients at risk of fall-related hospitalisations and poor quality of life, and evidence-based decision support to minimise these risks. Longer term plans for dashboard implementation and evaluation are also outlined. METHODS: This mixed-method study will involve (1) co-designing dashboard features with aged care staff, clients, informal caregivers and general practitioners (GPs), (2) integrating aged care data silos and developing risk models, and (3) testing dashboard prototypes with users. The dashboard features will be informed by direct observations of routine work, interviews, focus groups and co-design groups with users, and a community forum. Multivariable discrete time survival models will be used to develop risk indicators, using predictors from linked historical aged care and hospital data. Dashboard prototype testing will comprise interviews, focus groups and walk-through scenarios using a think-aloud approach with staff members, clients and informal caregivers, and a GP workshop. ETHICS AND DISSEMINATION: This study has received ethical approval from the New South Wales (NSW) Population & Health Services Research Ethics Committee and Macquarie University's Human Research Ethics Committee. The research findings will be presented to the aged care provider who will share results with staff members, clients, residents and informal caregivers. Findings will be disseminated as peer-reviewed journal articles, policy briefs and conference presentations.

A mixed-methods study evaluating the impact of an excursion-based social group on quality of life of older adults.

BACKGROUND: Social isolation is an increasing concern for older adults who live in the community. Despite some availability of social support programs to address social isolation, their effectiveness is not routinely measured. This study aimed to evaluate an innovative excursion-based program offering unique social experiences to older adults receiving aged care services. METHODS: This six-month before and after mixed-methods study evaluated the outcomes of an Australian excursion-based program which offered social and physical outings to bring older adults receiving aged care services into the wider community. The study combined two parts: Part 1 was a pre-post survey assessing the quality of life of older adults who received the excursion-based program for 6 months (n = 56; two time-points, analysed using signed rank test) and Part 2 involved qualitative in-depth, semi-structured interviews (n = 24 aged care staff, older adults and carers; analysed using thematic analysis). RESULTS: Older adults experienced a significant increase in quality of life scores (p < 0.001) between baseline and 6 months. Interviews confirmed these observations and suggested that benefits of participation included increased opportunities for social participation, psychological wellbeing, physical function, and carer respite. Interviews also revealed being in a group setting, having tailored, convenient and accessible activities, alongside supportive staff were key drivers in improving the wellbeing of participants. CONCLUSIONS: Participating in an excursion-based community program may improve wellbeing in older adults. Aging policy should focus on prioritizing initiatives that promote social connectivity with the wider community and assist in improving outcomes for older adults.

Comparison of the quick Sepsis-related Organ Failure Assessment and adult sepsis pathway in predicting adverse outcomes among adult patients in general wards: a retrospective observational cohort study.

BACKGROUND: Quick Sepsis-related Organ Failure Assessment (qSOFA) is recommended for use by the most recent international sepsis definition taskforce to identify suspected sepsis in patients outside the intensive care unit (ICU) at risk of adverse outcomes. Evidence of its comparative effectiveness with existing sepsis recognition tools is important to guide decisions about its widespread implementation. AIM: To compare the performance of qSOFA with the adult sepsis pathway (ASP), a current sepsis recognition tool widely used in NSW hospitals and systemic inflammatory response syndrome criteria in predicting adverse outcomes in adult patients on general wards. METHODS: A retrospective observational cohort study was conducted which included all adults with suspected infections admitted to a Sydney teaching hospital between December 2014 and June 2016. The primary outcome was in-hospital mortality with two secondary composite outcomes. RESULTS: Among 2940 patients with suspected infection, 217 (7.38%) died in-hospital and 702 (23.88%) were subsequently admitted to ICU. The ASP showed the greatest ability to correctly discriminate in-hospital mortality and secondary outcomes. The area under the receiver-operating characteristic curve for mortality was 0.76 (95% confidence interval (CI): 0.74-0.78), compared to 0.64 for the qSOFA tool (95% CI: 0.61-0.67, P < 0.0001). Median time from the first ASP sepsis warning to death was 8.21 days (interquartile range (IQR): 2.29-16.75) while it was 0 days for qSOFA (IQR: 0-2.58). CONCLUSIONS: The ASP demonstrated both greater prognostic accuracy and earlier warning for in-hospital mortality for adults on hospital wards compared to qSOFA. Hospitals already using ASP may not benefit from switching to the qSOFA tool.

International Comparison of Six Basic eHealth Indicators Across 14 Countries: An eHealth Benchmarking Study.

BACKGROUND: Many countries adopt eHealth applications to support patient-centered care. Through information exchange, these eHealth applications may overcome institutional data silos and support holistic and ubiquitous (regional or national) information logistics. Available eHealth indicators mostly describe usage and acceptance of eHealth in a country. The eHealth indicators focusing on the cross-institutional availability of patient-related information for health care professionals, patients, and care givers are rare. OBJECTIVES: This study aims to present eHealth indicators on cross-institutional availability of relevant patient data for health care professionals, as well as for patients and their caregivers across 14 countries (Argentina, Australia, Austria, Finland, Germany, Hong Kong as a special administrative region of China, Israel, Japan, Jordan, Kenya, South Korea, Sweden, Turkey, and the United States) to compare our indicators and the resulting data for the examined countries with other eHealth benchmarks and to extend and explore changes to a comparable survey in 2017. We defined "availability of patient data" as the ability to access data in and to add data to the patient record in the respective country. METHODS: The invited experts from each of the 14 countries provided the indicator data for their country to reflect the situation on August 1, 2019, as date of reference. Overall, 60 items were aggregated to six eHealth indicators. RESULTS: Availability of patient-related information varies strongly by country. Health care professionals can access patients' most relevant cross-institutional health record data fully in only four countries. Patients and their caregivers can access their health record data fully in only two countries. Patients are able to fully add relevant data only in one country. Finland showed the best outcome of all eHealth indicators, followed by South Korea, Japan, and Sweden. CONCLUSION: Advancement in eHealth depends on contextual factors such as health care organization, national health politics, privacy laws, and health care financing. Improvements in eHealth indicators are thus often slow. However, our survey shows that some countries were able to improve on at least some indicators between 2017 and 2019. We anticipate further improvements in the future.

Clinical thresholds for diagnosing iron deficiency: comparison of functional assessment of serum ferritin to population based centiles.

Low serum ferritin is diagnostic of iron deficiency, yet its published lower cut-off values are highly variable, particularly for pediatric populations. Lower cut-off values are commonly reported as 2.5th percentiles, and is based on the variation of ferritin values in the population. Our objective was to determine whether a functional approach based on iron deficient erythropoiesis could provide a better alternative. Utilizing 64,443 ferritin test results from pediatric electronic health records, we conducted various statistical techniques to derive 2.5th percentiles, and also derived functional reference limits through the association between ferritin and erythrocyte parameters: hemoglobin, mean corpuscular volume, mean cell hemoglobin concentration, and red cell distribution width. We find that lower limits of reference intervals derived as centiles are too low for clinical interpretation. Functional limits indicate iron deficiency anemia starts to occur when ferritin levels reach 10 µg/L, and are largely similar between genders and age groups. In comparison, centiles (2.5%) presented with lower limits overall, with varying levels depending on age and gender. Functionally-derived limits better reflects the underlying physiology of a patient, and may provide a basis for deriving a threshold related to treatment of iron deficiency and any other biomarker with functional outcomes.

Inside the black box of comparative national healthcare performance in 35 OECD countries: Issues of culture, systems performance and sustainability.

BACKGROUND: Is national healthcare performance associated with country-level characteristics, and if so what are the implications for international health policy? METHODS AND FINDINGS: We compared Hofstede's six cultural dimensions against relative health systems performance of 35 countries. Hierarchical cluster analysis identified best-matched groupings of countries. Performance was measured by the Organisation for Economic Co-operation and Development's (OECD's) Health at a Glance indicators data framework (five dimensions with 57 indicators) and the United Nations' (UNs') Sustainability Development Goals (SDG) data set (15 indicators). Three country clusters emerged: Collective-Pyramidal (n = 9: comprising Slovak Republic, Mexico, Poland, Greece, Spain, Turkey, Portugal, Chile, and Slovenia); Collaborative-Networked (n = 12: UK, Canada, Australia, USA, Ireland, New Zealand, Netherlands, Finland, Iceland, Norway, Denmark, and Sweden); and Orderly-Future Orientated (n = 14: Korea, Estonia, Latvia, Austria, Israel, Japan, Czech Republic, Hungary, Italy, Belgium, France, Germany, Luxembourg and Switzerland). The Collaborative-Networked cluster had significantly better performing health systems measured by both the Health at a Glance and SDG performance data, followed by the Orderly-Future Orientated cluster, followed by the Collective-Pyramidal cluster. The Collaborative-Networked Cluster was characterized by low power distance (e.g., greater levels of equity), low uncertainty avoidance (e.g., toleration of others' opinions), individualism (e.g., self-reliance) and indulgence (e.g., drives and norms to enjoy life and have fun). CONCLUSIONS: National cultures are associated with healthcare performance on two key international measures. In national and international efforts to improve health system performance, cultural characteristics play an important role. This information may be of value to regulators, policymakers, researchers and clinicians examining the practical impact of culture on healthcare performance.

Do user preferences align with human factors assessment scores of drug-drug interaction alerts?

This study aimed to assess drug-drug interaction alert interfaces and to examine the relationship between compliance with human factors principles and user-preferences of alerts. Three reviewers independently evaluated drug-drug interaction alert interfaces in seven electronic systems using the Instrument-for-Evaluating-Human-Factors-Principles-in-Medication-Related-Decision-Support-Alerts (I-MeDeSA). Fifty-three doctors and pharmacists completed a survey to rate the alert interfaces from best to worst and reported on liked and disliked features. Human factors compliance and user-preferences of alerts were compared. Statistical analysis revealed no significant association between I-MeDeSA scores and user-preferences. However, the strengths and weaknesses of drug-drug interaction alerts from users' perspectives were in-line with the human factors constructs evaluated by the I-MeDeSA. I-MeDeSA in its current form, is unable to identify alerts that are preferred by the users. The design principles assessed by I-MeDeSA appear to be sound, but its arbitrary allocation of points to each human factors construct may not reflect the relative importance that the end-users place on different aspects of alert design.

Appropriate management of acute gastroenteritis in Australian children: A population-based study.

OBJECTIVES: To determine the proportion of care provided to children with acute gastroenteritis (AGE) in Australia consistent with clinical practice guidelines. METHODS: Indicators were developed from national and international clinical practice guideline (CPG) recommendations and validated by an expert panel. Medical records from children ≤15 years presenting with AGE in three healthcare settings-Emergency Department (ED), hospital admissions and General Practitioner (GP) consultations-from randomly selected health districts across three Australian States were reviewed. Records were audited against 35 indicators by trained paediatric nurses, to determine adherence to CPGs during diagnosis, treatment, and ongoing management. RESULTS: A total of 14,434 indicator assessments were performed from 854 healthcare visits for AGE by 669 children, across 75 GPs, 34 EDs and 26 hospital inpatient services. Documented adherence to guidelines across all healthcare settings was 45.5% for indicators relating to diagnosis (95% CI: 40.7-50.4), 96.1% for treatment (95% CI: 94.8-97.1) and 57.6% for ongoing management (95% CI: 51.3-63.7). Adherence varied by healthcare setting, with adherence in GPs (54.6%; 95% CI: 51.1-58.1) lower than for either ED settings (84.7%; 95% CI: 82.4-86.9) or for inpatients (84.3%; 95% CI: 80.0-87.9); p<0.0001 for both differences. The difference between settings was driven by differences in the diagnosis and ongoing management phases of care. CONCLUSIONS: Adherence to clinical guidelines for children presenting to healthcare providers with AGE varies according to phase of care and healthcare setting. Although appropriate diagnostic assessment and ongoing management phase procedures are not well documented in medical records (particularly in the GP setting), in the treatment phase children are treated in accordance with guidelines over 90% of the time.

Inter-observer agreement and reliability assessment for observational studies of clinical work.

Inter-observer agreement (IOA) is a key aspect of data quality in time-and-motion studies of clinical work. To date, such studies have used simple and ad hoc approaches for IOA assessment, often with minimal reporting of methodological details. The main methodological issues are how to align time-stamped task intervals that rarely have agreeing start and end times, and how to assess IOA for multiple nominal variables. We present a combination of methods that simultaneously addresses both these issues and provides a more appropriate measure by which to assess IOA for time-and-motion studies. The issue of alignment is addressed by converting task-level data into small time windows then aligning data from different observers by time. A method applicable to multivariate nominal data, the iota score, is then applied to the time-aligned data. We illustrate our approach by comparing iota scores to the mean of univariate Cohen's kappa scores through application of these measures to existing data from an observational study of emergency department physicians. While the two scores generated very similar results under certain conditions, iota was more resilient to sparse data issues. Our results suggest that iota applied to time windows considerably improves on previous methods used for IOA assessment in time-and-motion studies, and that Cohen's kappa and other univariate measures should not be considered the gold standard. Rather, there is an urgent need for ongoing explicit discussion of methodological issues and solutions to improve the ways in which data quality is assessed in time-and-motion studies in order to ensure the conclusions drawn from such studies are robust.

What is multidisciplinary cancer care like in practice? a protocol for a mixed-method study to characterise ambulatory oncology services in the Australian public sector.

INTRODUCTION: An understanding of the real-world provision of oncology outpatient services can help maintain service quality in the face of escalating demand and tight budgets, by informing the design of interventions that improve the effectiveness or efficiency of provision. The aims of this study are threefold. First, to develop an understanding of cancer services in outpatient clinics by characterising the organisation and practice of multidisciplinary care (MDC). Second, to explore the key areas of: (a) clinical decision-making and (b) engagement with patients' supportive needs. Third, to identify barriers to, and facilitators of, the delivery of quality care in these settings. METHODS AND ANALYSIS: A suite of mixed-methods studies will be implemented at six hospitals providing cancer outpatient clinics, with a staged roll-out. In Stage One, we will examine policies, use unstructured observations and undertake interviews with key health professionals to characterise the organisation and delivery of MDC. In Stage Two, observations of practice will continue, to deepen our understanding, and to inform two focused studies. The first will explore decision-making practices and the second will examine how staff engage with patients' needs; both studies involve interviews, to complement observation. As part of the study of supportive care, we will examine the implications of an introduction of patient-reported measures (PRMs) into care, adding surveys to interviews before and after PRMs roll-out. Data analysis will account for site-specific and cross-site issues using an adapted Qualitative Rapid Appraisal, Rigorous Analysis approach. Quantitative data from clinician surveys will be statistically analysed and triangulated with the related qualitative study findings. ETHICS AND DISSEMINATION: Ethical approval was granted by South Eastern Sydney Local Health District Human Research Ethics Committee (no. 18/207). Findings will be shared with participating hospitals and widely disseminated through publications and presentations.

Diagnostic Informatics: Its Role in Enhancing Clinical Excellence, Patient Safety and the Value of Care.

Diagnostic informatics encompasses the role of information technology in key areas of the diagnostic testing (pathology and medical imaging) process, including the selection of appropriate tests and interpretation and follow-up of test results. We present three case studies employing diagnostic informatics methodologies to demonstrate their potential use and value in health services research: (1) Data analytics applied to diagnostic data linked with patient outcome data as a means of enhanancing the monitoring of the quality and appropriateness of diagnostic test choices; (2) Business process modelling which can help to highlight healthcare processes in the diagnostic pathway as a means of improving safety and performance, and (3) Consumer involvement in the diagnostic research process to assist in the establishment of person-centred test result management systems. The case studies provide evidence of the role that diagnostic informatics can have in improving the quality and safety of patient care.