Unpacking the cost of the lunchbox for Australian families: a secondary analysis.

Ninety per cent of Australian school children bring a home-packed lunch to school, with 44% of the food consumed during school hours being unhealthy. Among other factors, cost is a key consideration for food provision; however, the costs to Australian families are not well understood. Therefore, we aimed to determine what families are currently paying for school lunchboxes in Australian primary schools and to examine associations between food costs and socio-demographic factors with dietary quality. An audit of local retail outlets was used to determine the food costs of lunchbox contents. Costs (AUD) were adjusted for inflation as of early 2023. The lunchboxes of 1026 children aged 4-12 years at 12 Catholic primary schools in New South Wales, Australia, were assessed at the start of the day, using photography assessment methods and a validated School Food Checklist. The mean cost of lunchbox contents was $4.48 AUD (SD 1.53), containing a mean energy of 2699 kJ (SD 859), with 37.3% (SD 23.9) of energy sourced from unhealthy foods. Multiple linear regression analyses found that the strongest predictors of higher lunchbox cost (P < 0.05) were a higher proportion of energy from unhealthy foods (B = 0.016) and lower Socio-Economic Indexes for Areas (B = -0.178), when controlling for child socio-demographics. The results indicated that lunchbox food costs to Australian families are comparable to alternative school food service models in Australia and internationally. Results demonstrate the cost of food is not the only barrier to providing a healthy school lunchbox. Demonstrating a need for cost-considerate systematic interventions addressing food provision challenges and socio-economic disparities faced by families.

The economic costs of alcohol-related harms at the local level in New South Wales.

INTRODUCTION: Alcohol is a harmful, toxic and addictive substance that causes many diseases and injuries. Alcohol use also incurs a financial cost to the health care system and wider economy. This project aimed to undertake a cost impact analysis of alcohol-related harms at the local level in New South Wales (NSW). The alcohol-related harms costing model is an interactive tool designed for use by local health districts, stakeholders such as Liquor and Gaming NSW, NSW Independent Liquor and Gaming Authority and community stakeholders. METHODS: Costs included in the analysis were alcohol-related hospitalisations, deaths, crimes, emergency department attendances, outpatient presentations and their impacts on productivity. Two local government areas (LGA) were used as case studies to demonstrate local impacts. RESULTS: In 2019-2020, the total cost of alcohol-related harms for NSW was estimated at $9 billion, at a rate of $120.3 million per 100,000 population. The total costs were comprised of alcohol-attributable premature mortality ($8.3 billion), non-fatal health care costs ($275 million) and crime costs ($457 million). A comparative analysis of two case study LGAs estimated that alcohol-related harms cost $195 million for the Northern Beaches LGA and $351 million for the Central Coast LGA. DISCUSSION AND CONCLUSIONS: This research has developed a 'proof-of-concept' model to estimate the cost of alcohol-related harms at the local level in Australia, empowering health agencies and local community stakeholders to use economic evidence in their submissions in response to new liquor licence applications and other policies that impact their local community. This economic evidence can be used to improve the quality of decisions on alcohol regulation and policies. There are a number of future research opportunities that would enhance the economic evidence available to liquor licensing decision-makers.

Improved survival at the cost of more chronic lung disease? Current management and outcomes in extremely preterm infants born in New South Wales and the Australian Capital Territory: 2010-2020.

BACKGROUND: Since 2010, most tertiary care hospitals in Australia have changed how they care for extremely premature infants. However, in-hospital and longer-term outcome data have suggested unchanged or even worse health outcomes in later epochs, especially respiratory outcomes. This study examined the trend in outcomes since these changes were introduced, particularly the prevalence of chronic neonatal lung disease (CLD). METHODS: This is a retrospective cross-sectional analysis of data from the Neonatal Intensive Care Units' (NICUS) database of all perinatal intensive care units in New South Wales and the Australian Capital Territory, including infants born at ≥ 24 and ≤ 28 weeks of gestational age in tertiary perinatal units between January 1, 2010, and December 31, 2020. Temporal trends and changes in primary outcome were examined by linear and adjusted multivariable logistic regression models. RESULTS: This study included 3258 infants. We saw significant changes in antenatal magnesium sulfate (75% increase), delayed cord clamping (66% increase), delivery room intubations (30% decrease), any time (20% decrease), duration on mechanical ventilation (100-hour decrease), and hours on noninvasive ventilation (200-hour increase). Mortality decreased from 17% to 6%. The incidence of CLD increased significantly even when adjusted for confounders (15% increase). Any time and mean hours spent on mechanical ventilation significantly increased the odds of CLD. This study could not find a significant association of any of the protective antenatal treatments on CLD. CONCLUSIONS: The last decade saw a significant improvement in survival and survival to discharge without major morbidity. There was increased use of magnesium sulfate, delayed cord clamping, and less invasive respiratory management of extremely preterm infants. The avoidance of mechanical ventilation may impact the incidence of CLD.

Characterising the Aboriginal and Torres Strait Islander patient journey after a serious road traffic injury and barriers to access to compensation: a protocol.

INTRODUCTION: Road safety has been a long-enduring policy concern in Australia, with significant financial burden of road trauma and evident socioeconomic disparities. Transport injuries disproportionately impact individuals in remote areas, those in lower socioeconomic situations, and Aboriginal and Torres Strait Islander populations. There is a lack of insight into transport injuries in Aboriginal and Torres Strait Islander communities, absence of Indigenous perspective in published research and limited utilisation of linked data assets to address the inequity. Aim 1 is to determine the breadth, cost and causal factors of serious injury from road traffic crashes in South Australia (SA) and New South Wales (NSW) with a focus on injury prevention. Aim 2 is to identify enablers and barriers to compensation schemes for Aboriginal and Torres Strait Islander patients in SA and NSW. METHODS AND ANALYSIS: This study will be guided by an Aboriginal and Torres Strait Islander Governance Group, applying Knowledge Interface Methodology and Indigenous research principles to ensure Indigenous Data Sovereignty and incorporation of informed perspectives. A mixed-method approach will be undertaken to explore study aims including using big data assets and mapping patient journey. CONCLUSION: The results of this study will provide valuable insights for the development of focused injury prevention strategies and policies tailored to Aboriginal and Torres Strait Islander communities. By addressing the specific needs and challenges faced by these communities, the study aims to enhance road safety outcomes and promote equitable access to healthcare and compensation for affected individuals and their families.

Developing a climate change inequality health impact assessment for health services.

OBJECTIVES: To develop a Climate Change Inequality Health Impact Assessment (CCIHIA) framework for health services; to provide a systematic process for assessing potential unequal health impacts of climate change on vulnerable and marginalised populations and places; to support effective planning to address these impacts; and to develop contextually appropriate local strategies. Type of program: A collaborative interdisciplinary scoping research project involving two universities and two local health districts (LHDs) in New South Wales (NSW) to develop a CCIHIA framework. This work builds upon the health impact assessment (HIA) approach, which systematically assesses proposals' potential health and equity impacts by involving stakeholders in developing responses. METHODS: The project involved four main activities: understanding stakeholder requirements; conceptualising climate change vulnerability; considering the role of health services; and integrating findings into a conceptual framework. RESULTS: Stakeholders identified key functions that should be addressed across the framing, process and utility of the CCIHIA framework. The resulting conceptual framework outlines contexts and social stratification, the differential impacts of climate change (including factors influencing unequal impacts) and the health system's position, and also identifies key potential points of intervention. LESSONS LEARNT: The challenge of addressing the complexity of factors and resulting health impacts is reflected within the CCIHIA framework. While there are many intervention points within this framework for health services to address, many factors influencing unequal impacts are created outside the health sector's direct control. The framework's development process reflected the focus on collaboration and the interdisciplinary nature of climate change response. Ultimately, the CCIHIA framework is an assessment tool and an approach for prioritising inclusive, cross-cutting, multisector working, and problem-solving.

Gaawaadhi Gadudha: understanding how cultural camps impact health, well-being and resilience among Aboriginal adults in New South Wales, Australia-a collaborative study protocol.

INTRODUCTION: The health and well-being of Aboriginal Australians is inextricably linked to culture and Country. Our study challenges deficit approaches to health inequities by seeking to examine how cultural connection, practice and resilience among Aboriginal peoples through participation in 'cultural camps' held on sites of cultural significance promotes health and well-being. METHODS AND ANALYSIS: The study will be undertaken in close collaboration and under the governance of traditional cultural knowledge holders from Yuwaalaraay, Gamilaraay and Yuin nation groups in New South Wales, Australia. Three cultural camps will be facilitated, where participants (n=105) will engage in activities that foster a connection to culture and cultural landscapes. A survey assessing connection to culture, access to cultural resources, resilience, self-rated health and quality of life will be administered to participants pre-camp and post-camp participation, and to a comparative group of Aboriginal adults who do not attend the camp (n=105). Twenty participants at each camp (n=60) will be invited to participate in a yarning circle to explore cultural health, well-being and resilience. Quantitative analysis will use independent samples' t-tests or χ2 analyses to compare camp and non-camp groups, and linear regression models to determine the impact of camp attendance. Qualitative analysis will apply inductive coding to data, which will be used to identify connections between coded concepts across the whole data set, and explore phenomenological aspects. Results will be used to collaboratively develop a 'Model of Cultural Health' that will be refined through a Delphi process with experts, stakeholders and policymakers. ETHICS AND DISSEMINATION: The study has ethics approval from the Aboriginal Health and Medical Research Council (#1851/21). Findings will be disseminated through a combination of peer-reviewed articles, media communication, policy briefs, presentations and summary documents to stakeholders.

Evaluation of a mental health service reform program, the Pathways to Community Living Initiative, for people with severe mental illness and complex needs.

OBJECTIVE: The Pathways to Community Living Initiative (PCLI) aims to reform mental health care for people with severe and persistent mental illness (SPMI) and complex needs. This study reports independent evaluation findings on transitions from hospital and practice change in mental health services. METHODS: Data for this mixed-methods evaluation were obtained from administrative collections and semi-structured interviews with PCLI program managers, teams and executive leads; aged care managers; and leaders in inpatient, community and older people's mental health services. RESULTS: Between July 2015 and December 2020, 674 participants (67% of those eligible for the PCLI) were transitioned from hospital to community. Of those transitioned, 21 required subsequent long-stay admissions. The PCLI introduced resources, clearly defined processes, and state-wide networks to guide changes in practice which are becoming embedded in the operations and governance of mental health services across New South Wales. CONCLUSIONS: Severe and persistent mental illness and complex needs can be managed in community settings with highly individualised planning and care, supported by specialised clinical teams in partnership with mental health, aged care and disability services. Evaluation findings highlight the importance of continued investment in rehabilitation psychiatry.

A qualitative exploration of young people's mental health needs in rural and regional Australia: engagement, empowerment and integration.

BACKGROUND: Australian rural and regional communities are marked by geographic isolation and increasingly frequent and severe natural disasters such as drought, bushfires and floods. These circumstances strain the mental health of their inhabitants and jeopardise the healthy mental and emotional development of their adolescent populations. Professional mental health care in these communities is often inconsistent and un-coordinated. While substantial research has examined the barriers of young people's mental health and help-seeking behaviours in these communities, there is a lack of research exploring what adolescents in rural and regional areas view as facilitators to their mental health and to seeking help when it is needed. This study aims to establish an in-depth understanding of those young people's experiences and needs regarding mental health, what facilitates their help-seeking, and what kind of mental health education and support they want and find useful. METHOD: We conducted a qualitative study in 11 drought-affected rural and regional communities of New South Wales, Australia. Seventeen semi-structured (14 group; 3 individual) interviews were held with 42 year 9 and 10 high school students, 14 high school staff, and 2 parents, exploring participants' experiences of how geographical isolation and natural disasters impacted their mental health. We further examined participants' understandings and needs regarding locally available mental health support resources and their views and experiences regarding mental illness, stigma and help-seeking. RESULTS: Thematic analysis highlighted that, through the lens of participants, young people's mental health and help-seeking needs would best be enabled by a well-coordinated multi-pronged community approach consisting of mental health education and support services that are locally available, free of charge, engaging, and empowering. Participants also highlighted the need to integrate young people's existing mental health supporters such as teachers, parents and school counselling services into such a community approach, recognising their strengths, limitations and own education and support needs. CONCLUSIONS: We propose a three-dimensional Engagement, Empowerment, Integration model to strengthen young people's mental health development which comprises: 1) maximising young people's emotional investment (engagement); 2) developing young people's mental health self-management skills (empowerment); and, 3) integrating mental health education and support programs into existing community and school structures and resources (integration).

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals.

BACKGROUND: International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). METHODS: We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017-2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors. RESULTS: Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45-0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients. CONCLUSION: Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

Serum vitamin C status of people in New South Wales: retrospective analysis of findings at a public referral hospital.

OBJECTIVES: To examine the relationship between vitamin C status and demographic factors in New South Wales on the basis of serum vitamin C test results undertaken at the central pathology laboratory in Sydney, and to assess associations with age, gender, social disadvantage, and geographic remoteness. DESIGN, SETTING: Retrospective observational study; analysis of vitamin C test results undertaken at the Royal Prince Alfred Hospital, 1 January 2017 - 31 December 2021. MAIN OUTCOME MEASURES: Vitamin C status (normal, serum concentration ≥ 40 µmol/L; hypovitaminosis C, 12-39 µmol/L; significant deficiency, < 12 µmol/L); associations of vitamin C status with year of testing, age, gender, socio-economic status (Index of Relative Socio-Economic Advantage and Disadvantage quintile), and geographic remoteness (Australian Statistical Geography Standard); rate of hypovitaminosis C or significant deficiency test results (relative to findings of normal levels; per 100 000 estimated resident population) by Statistical Area 3. RESULTS: Of 17 507 vitamin C tests undertaken during 2017-2021, 4573 were excluded (multiple tests for individuals); of 12 934 included results, 6654 were for women (51.5%), 9402 for people living in major cities (73.5%), and 81 for people in remote or very remote areas (0.6%). In multivariable multinomial regression analyses, significant deficiency (relative to normal test results) was more likely for men than women (adjusted odds ratio [aOR], 1.39; 95% confidence interval [CI], 1.27-1.52); the likelihood of hypovitaminosis C (IRSAD quintile 1 v 5, aOR, 1.35; 95% CI, 1.19-1.53) or significant deficiency (aOR, 2.07; 95% CI, 1.79-2.40) generally increased with postcode-level socio-economic disadvantage. Several of the population areas with the highest low vitamin C rates were areas of greatest disadvantage in NSW. CONCLUSIONS: The prevalence of vitamin C deficiency among older people and people living in areas of socio-economic disadvantage indicates that population assessment of vitamin C levels would be appropriate.

'Fragmented care': Asylum seekers' experience of accessing health care in NSW.

Medicare is central to accessing health care in Australia, yet many asylum seekers are ineligible for this scheme. In NSW, Medicare ineligible asylum seekers have some access to public health care under the Medicare Ineligible Asylum Seekers - Provision of Specified Public Health Services policy. This policy was updated in November 2020 to clarify services where a fee waiver applies for asylum seekers without Medicare. We examined the experiences of Medicare ineligible asylum seekers in accessing health care in New South Wales (NSW) in light of the revised policy. Employing qualitative methods, we conducted semi-structured interviews with asylum seekers (n = 7) and service providers (n = 6) in South Western Sydney. The interviews were analysed using thematic analysis and the socio-ecological model was used to interpret the data. Participants identified that chronic and mental health conditions are the main health issues for asylum seekers. Factors across the four levels of the socio-ecological model were identified as influencing the health care of asylum seekers, including a lack of awareness about health care rights at the individual level, support from relatives and friends at the interpersonal level, providers' lack of awareness of fee waivers at the organizational level and limited access to primary health care at the policy level. The results imply that Medicare ineligible asylum seekers in NSW do not have optimal access to health care which may worsen existing health disparities. Educational initiatives that improve service providers' and asylum seekers' awareness of the revised policy are needed to improve asylum seeker health equity in NSW.

Why do mothers stay? Challenging attitudes in decision making about children at risk because of domestic violence.

BACKGROUND: This article reports findings from research commenced in 2019. Stage one assessed the attitudes and beliefs of child protection practitioners towards domestic violence. Stage two considered the impact of combining Structured Decision Making (SDM - the standard assessment approach) with Response Based Practice (RBP - a contemporary approach to understanding violence), on child protection decisions. OBJECTIVE: To improve the child protection response to children who experience domestic violence. This article reports on stage three; considering the impact of practitioner attitudes and beliefs on child protection decisions and whether the combined assessment approach (SDM + RBP) moderated the impact of practitioner attitudes and beliefs. PARTICIPANTS AND SETTING: 1041 child protection practitioners participated in the research while attending one of 17 practice conferences across New South Wales, Australia. METHODS: An innovative video vignette experiment with a between-subjects design was used, relying on professional actors to play the roles of practitioner and mother of the children reported. Participants watched a video interview of a safety assessment and completed a survey. RESULTS: Practitioner attitudes and beliefs were not significantly correlated with assessments about the children's safety; but attitudes did impact decisions about the likelihood of the children being brought into care. Attitudes and beliefs moderated the impact of misinformed attitudes, to some extent. CONCLUSIONS: The research confirms the value of the combined SDM + RBP approach to guide practitioners to a more holistic understanding of domestic violence. It also confirms that assessment approaches are only ever as good as the beliefs and attitudes of the people who apply them.

Development and piloting of a Community of Practice to support learning and improvement in health promotion practice within NSW local health district.

OBJECTIVES: Health Promotion Units within New South Wales (NSW) local health districts (LHDs) frequently collaborate and test innovations to address priority health issues or approaches to support the implementation of a health promotion program in a way that is consistent with the needs, resources, and contexts of their regions. Compatible with learning health system approaches, mechanisms to facilitate the exchange of evidence and expertise across districts could improve the collective impact of health promotion services across the state. This study aimed to assess the use of a health promotion Community of Practice (CoP) model as a strategy to achieve this. Type of program or service: This paper describes and shares experiences from the development and piloting process of a CoP model to develop, evaluate and exchange learnings to improve approaches to support the adoption of an effective healthy lunchbox program ('SWAP IT') across three LHDs. RESULTS: The functioning of the CoP was supported by key activities, funding and infrastructure over a 2-year period, including: planning workshops, implementation check-ins, and knowledge exchange meetings. A particularly novel aspect of the CoP was the harmonised evaluation of different, locally developed strategies to facilitate program adoption across the three LHDs. The alignment of the CoP with local and state priorities, as well as the operation of the CoP in a way that did not impose significant time demands, was seen as important for the sustainability of the CoP. LESSONS LEARNT: Findings from the piloting process suggest that a formalised CoP shows promise as an effective model to enhance health promotion collaboration, information sharing and practice across LHDs, which may be suitable for broader application across the state.

Health literacy strengths and challenges of people in New South Wales prisons: a cross-sectional survey using the Health Literacy Questionnaire (HLQ).

BACKGROUND: Health literacy is an important factor for enabling people to manage their health and live long fulfilling lives. People in prison are frequently from marginalised communities, often out of reach of conventional community based health organisations, and have poorer health outcomes. It is essential to understanding the health literacy profiles of people in prison, and its contribution to the well-established health inequities and outcomes of this population. This study aimed to use a multi-dimensional health literacy measurement tool to describe the strengths and challenges of adults incarcerated in NSW prisons. METHODS: A cross-sectional survey was conducted for people in prison across 14 publicly operated metropolitan prisons. Data were collected from 471 participants using the Health Literacy Questionnaire (HLQ). Participant characteristics and health conditions were also collected. Data were analysed using descriptive statistics. Effect sizes (ES) for standardised differences in means were used to describe the magnitude of difference between participant characteristic groups. RESULTS: Participants' median age was 38.0 (range 19 - 91) years. Males comprised 81% of the sample, 21% identified as Aboriginal and/or Torres Strait Islander, and 53% reported a health problem. People in prison had lower scores for all nine HLQ scales when compared to the general Australian population. Small to medium ES were seen for mean differences between most demographic groups. Compared to males, females had lower scores for several of the HLQ scales including 'having sufficient information to manage health' (ES 0.30 [95% Confidence Interval (CI) 0.07, 0.53]), 'ability to actively engage with health care professionals' (ES 0.30 [95% CI 0.06, 0.53]), 'navigating the healthcare system' (ES 0.30 [95% CI 0.06, 0.53]), and, 'ability to find good health information' (ES 0.33 [95% CI 0.10, 0.57]). Differing health literacy scale scores with small to medium ES were found when comparing participants by legal status. Mainly small ES were seen when comparing other participant characteristic groups. CONCLUSIONS: This study provides insights into the health literacy strengths and challenges for people in NSW prisons. These findings highlight the important role health literacy could have in addressing health disparities in this vulnerable population and can inform prison health services.

Audit of surgeon billing in workers compensation-insured elective spinal surgery in New South Wales, Australia from 2010 to 2018.

BACKGROUND: Medical billing practices have received increasing scrutiny in Australia and worldwide. In 2015, the Australian Government initiated a comprehensive review of the Medicare Benefits Schedule (MBS), including spinal surgery. This study provides a snapshot of five spinal surgeon billing patterns and associated costs in the workers compensation system in New South Wales prior to these changes. METHODS: This retrospective cohort study used workers compensation billing data from the State Insurance Regulatory Authority to capture elective spinal surgeries in New South Wales from 2010 to 2018. The main outcome measures were: proportion of items billed within recommended limits (up to 150% of the listed Australian Medical Association (AMA) fee); surgical billing patterns including repeat billing of items during a single episode of surgery; use of paediatric or scoliosis items; use of surgical items from outside the spinal surgery schedule; co-billing of items not permitted as per the AMA Fees List item descriptions and associated costs. RESULTS: There were 12 622 spinal surgeries in 9520 patients. While only 2.2% of items were billed above the recommended limits, 38% of surgeries included at least one of the five billing patterns. The average cost increase was AU$4700 per surgery, 47% greater than surgeries which did not include the specified billing patterns, for a total additional cost of AU$22.9 M over the 9-year study period. CONCLUSION: Five spinal surgery billing patterns accounted for an additional AU$22.9 million in direct surgical costs from 2010 to 2018.

Health workers' perspectives of hepatitis B-related stigma among Aboriginal and Torres Strait Islander people in New South Wales, Australia.

BACKGROUND: Experiences of stigma and discrimination can act as a significant barrier to testing, monitoring, and treatment for hepatitis B virus (HBV). Aboriginal and Torres Strait Islander Australians are a population disproportionately impacted by HBV and yet limited research has explored HBV-related stigma in these communities. To begin preliminary explorations of HBV-related stigma among Aboriginal and Torres Strait Islander people, we interviewed health workers about their perceptions regarding HBV infection and HBV-related stigma. METHODS: Participants were recruited from staff involved in the Deadly Liver Mob (DLM) program which is a health promotion program that offers incentives for Aboriginal and Torres Strait Islander clients to be educated on viral hepatitis, recruit and educate peers, and receive screening and treatment for blood-borne viruses (BBVs) and sexually transmissible infections (STIs), and vaccination. Semi-structured interviews were conducted with 11 Aboriginal and Torres Strait Islander and non-Aboriginal or Torres Strait Islander health workers who have been involved in the development, implementation, and/or management of the DLM program within participating services in New South Wales, Australia. RESULTS: Findings suggest that stigma is a barrier to accessing mainstream health care among Aboriginal and Torres Strait Islander clients, with stigma being complex and multi-layered. Aboriginal and Torres Strait Islander people contend with multiple and intersecting layers of stigma and discrimination in their lives, and thus HBV is just one dimension of those experiences. Health workers perceived that stigma is fuelled by multiple factors, including poor HBV health literacy within the health workforce broadly and among Aboriginal and Torres Strait Islander clients, shame about social practices associated with viral hepatitis, and fear of unknown transmission risks and health outcomes. The DLM program was viewed as helping to resist and reject stigma, improve health literacy among both health workers and clients, and build trust and confidence in mainstream health services. CONCLUSIONS: Health promotion programs have the potential to reduce stigma by acting as a 'one stop shop' for BBVs and STIs through one-on-one support, yarning, and promotion of the HBV vaccine, monitoring for chronic HBV, and treatment (where required).

Experience-based codesign approach to improve care in Australian emergency departments for complex consumer cohorts: the MyED project protocol, Stages 1.1-1.3.

INTRODUCTION: Emergency department (ED) care must adapt to meet current and future demands. In Australia, ED quality measures (eg, prolonged length of stay, re-presentations or patient experience) are worse for older adults with multiple comorbidities, people who have a disability, those who present with a mental health condition, Indigenous Australians, and those with a culturally and linguistically diverse (CALD) background. Strengthened ED performance relies on understanding the social and systemic barriers and preferences for care of these different cohorts, and identifying viable solutions that may result in sustained improvement by service providers. A collaborative 5-year project (MyED) aims to codesign, with ED users and providers, new or adapted models of care that improve ED performance, improve patient outcomes and improve patient experience for these five cohorts. METHODS AND ANALYSIS: Experience-based codesign using mixed methods, set in three hospitals in one health district in Australia. This protocol introduces the staged and incremental approach to the whole project, and details the first research elements: ethnographic observations at the ED care interface, interviews with providers and interviews with two patient cohorts-older adults and adults with a CALD background. We aim to sample a diverse range of participants, carefully tailoring recruitment and support. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Western Sydney Local Health District Human Research Ethics Committee (2022/PID02749-2022/ETH02447). Prior informed written consent will be obtained from all research participants. Findings from each stage of the project will be submitted for peer-reviewed publication. Project outputs will be disseminated for implementation more widely across New South Wales, Australia.

Travel-associated cost savings to patients and the health system through provision of specialist head and neck surgery outreach clinics in rural New South Wales, Australia.

INTRODUCTION: Centralisation of head and neck surgical services means that patients in regional and remote Australia need to travel long distances for treatment and follow-up, imparting a significant financial burden on patients and the health system. OBJECTIVE: To estimate costs of travel to local outreach clinics and determine potential cost savings to patients and the health system by avoiding patient travel to major cities for head and neck surgical care. DESIGN: Retrospective audit of three head and neck surgery outreach clinics in New South Wales, Australia over 4 years (2017-2020). Direct costs of travel from a patient's residence to their local outreach clinic were estimated. Costs of travel and accommodation to Sydney for an appointment were calculated for different travel modes. Estimated reimbursements for travel through government support schemes were calculated based on published rates. FINDINGS: Some 657 patients attended the three clinics, accounting for 1981 appointments. Depending on mode of travel, the estimated median cost of return travel (including accommodation) to Sydney was $379 to $739 per patient per trip and the median government reimbursement ranged from $182 to $279 per trip. In comparison, the cost of return travel by car to local outreach clinics ranged from $28 to $163 per appointment. Outreach clinics were estimated to save patients a median of $285 per trip and avoided government reimbursements of $215 per trip. DISCUSSION: Despite uptake in telehealth, outreach medical services remain an important asset for people living in regional areas to address inequities in access. However, the cost benefits are likely to be underestimated as our approach did not account for indirect costs associated with travel. CONCLUSION: Outreach head and neck surgical services located in regional areas can reduce the financial burden on both patients and the healthcare system. Greater investment in outreach clinics could ensure sustainability of services to promote equitable access to specialised surgical services.

Provider responses to the expansion of public subsidies in healthcare: The case of oral chemotherapy treatment in Australia.

We examine provider responses to the expansion of public subsidies in 2015 for innovative oral chemotherapy treatment, in a health system where providers were free to determine their own prices. The new treatment was known to have similar efficacy to its traditional intravenous alternative and was preferred by patients for its at-home administration. However, from a policymaker's perspective, the potential for misalignment between patient and provider preferences was significant given the shift to full reimbursement for the oral chemotherapy medication but no change in fee-for-service payments for associated chemotherapy services. Under this scenario, a shift away from traditional intravenous chemotherapy may entail reduced activity and revenues associated with infusions for providers, and we hypothesise that it may result in unintended policy consequences such as reduced take-up of the new therapy or higher prices. We implement a difference-in-difference model using national administrative data on services provided, and chemotherapy medications prescribed, by providers to 1850 patients in New South Wales, Australia. Our estimates indicate that the subsidies expanded access to oral chemotherapy for newly eligible patients by 15 percentage points. However, prices charged by providers for an episode of care rose by 23 percent, driven mostly by increases in service volumes. The results illustrate the importance of understanding differential provider responses to policy changes in financial incentives.

Elective spinal surgery in New South Wales adults, 2001-20, by procedure funding type: a cross-sectional study.

OBJECTIVE: To investigate elective rates of spinal fusion, decompression, and disc replacement procedures for people with degenerative conditions, by funding type (public, private, workers' compensation). DESIGN, SETTING: Cross-sectional study; analysis of hospitals admissions data extracted from the New South Wales Admitted Patient Data Collection. PARTICIPANTS: All adults who underwent elective spinal surgery (spinal fusion, decompression, disc replacement) in NSW, 1 July 2001 - 30 June 2020. MAIN OUTCOME MEASURES: Crude and age- and sex-adjusted procedure rates, by procedure, funding type, and year; annual change in rates, 2001-20, expressed as incidence rate ratios (IRRs). RESULTS: During 2001-20, 155 088 procedures in 129 525 adults were eligible for our analysis: 53 606 fusion, 100 225 decompression, and 1257 disc replacement procedures. The privately funded fusion procedure rate increased from 26.6 to 109.5 per 100 000 insured adults (per year: IRR, 1.06; 95% confidence interval [CI], 1.05-1.07); the workers' compensation procedure rate increased from 6.1 to 15.8 per 100 000 covered adults (IRR, 1.04; 95% CI, 1.01-1.06); the publicly funded procedure rate increased from 5.6 to 12.4 per 100 000 adults (IRR, 1.03; 95% CI, 1.01-1.06), and from 10.5 to 22.1 per 100 000 adults without hospital cover private health insurance (IRR, 1.03; 95% CI, 1.01-1.05). The privately funded decompression procedure rate increased from 93.4 to 153.6 per 100 000 people (IRR, 1.02; 95% CI, 1.01-1.03); the workers' compensation procedure rate declined from 19.7 to 16.7 per 100 000 people (IRR, 0.98; 95% CI, 0.96-0.99), and the publicly funded procedure rate did not change significantly. The privately funded disc replacement procedure rate increased from 6.2 per million in 2010-11 to 38.4 per million people in 2019-20, but did not significantly change for the other two funding groups. The age- and sex-adjusted rates for privately and publicly funded fusion and decompression procedures were similar to the crude rates. CONCLUSIONS: Privately funded spinal surgery rates continue to be larger than for publicly funded procedures, and they have also increased more rapidly. These differences may indicate that some privately funded procedures are unnecessary, or that the number of publicly funded procedures does not reflect clinical need.