The Australian Health Care Homes trial: quality of care and patient outcomes. A propensity score-matched cohort study.

OBJECTIVE: To assess the impact of the Health Care Homes (HCH) primary health care initiative on quality of care and patient outcomes. DESIGN, SETTING: Quasi-experimental, matched cohort study; analysis of general practice data extracts and linked administrative data from ten Australian primary health networks, 1 October 2017 - 30 June 2021. PARTICIPANTS: People with chronic health conditions (practice data extracts: 9811; linked administrative data: 10 682) enrolled in the HCH 1 October 2017 - 30 June 2019; comparison groups of patients receiving usual care (1:1 propensity score-matched). INTERVENTION: Participants were involved in shared care planning, provided enhanced access to team care, and encouraged to seek chronic condition care at the HCH practice where they were enrolled. Participating practices received bundled payments based on clinical risk tier. MAIN OUTCOME MEASURES: Access to care, processes of care, diabetes-related outcomes, hospital service use, risk of death. RESULTS: During the first twelve months after enrolment, the mean numbers of general practitioner encounters (rate ratio, 1.14; 95% confidence interval [CI], 1.11-1.17) and Medicare Benefits Schedule claims for allied health services (rate ratio, 1.28; 95% CI, 1.24-1.33) were higher for the HCH than the usual care group. Annual influenza vaccinations (relative risk, 1.20; 95% CI, 1.17-1.22) and measurements of blood pressure (relative risk, 1.09; 95% CI, 1.08-1.11), blood lipids (relative risk, 1.19; 95% CI, 1.16-1.21), glycated haemoglobin (relative risk, 1.06; 95% CI, 1.03-1.08), and kidney function (relative risk, 1.13; 95% CI, 1.11-1.15) were more likely in the HCH than the usual care group during the twelve months after enrolment. Similar rate ratios and relative risks applied in the second year. The numbers of emergency department presentations (rate ratio, 1.09; 95% CI, 1.02-1.18) and emergency admissions (rate ratio, 1.13; 95% CI, 1.04-1.22) were higher for the HCH group during the first year; other differences in hospital use were not statistically significant. Differences in glycaemic and blood pressure control in people with diabetes in the second year were not statistically significant. By 30 June 2021, 689 people in the HCH group (6.5%) and 646 in the usual care group (6.1%) had died (hazard ratio, 1.07; 95% CI, 0.96-1.20). CONCLUSIONS: The HCH program was associated with greater access to care and improved processes of care for people with chronic diseases, but not changes in diabetes-related outcomes, most measures of hospital use, or risk of death.

Using a theoretical framework to inform implementation of the patient-centred medical home (PCMH) model in primary care: protocol for a mixed-methods systematic review.

BACKGROUND: The patient-centred medical home (PCMH) was conceived to address problems that primary care practices around the world are facing, particularly in managing the increasing numbers of patients with multiple chronic diseases. The problems include fragmentation, lack of access and poor coordination. The PCMH is a complex intervention combining high-quality primary care with evidence-based disease management. Becoming a PCMH takes time and resources, and there is a lack of empirically informed guidance for practices. Previous reviews of PCMH implementation have identified barriers and enablers but failed to analyse the complex relationships between factors involved in implementation. Using a theoretical framework can help with this, giving a better understanding of how and why interventions work or do not work. This review will aim to refine an existing theoretical framework for implementing organisational change - the Consolidated Framework for Implementation Research (CFIR) - to apply to the implementation of the PCMH in primary care. METHODS: We will use the 'best-fit' framework approach to synthesise evidence for implementing the PCMH in primary care. We will analyse evidence from empirical studies against CFIR constructs. Where studies have identified barriers and enablers to implementing the PCMH not represented in the CFIR constructs, we will use thematic analysis to develop additional constructs to refine the CFIR. Searches will be undertaken in MEDLINE (Ovid), Embase (Ovid), Web of Science Core Collection (including Science Citation Index and Social Science Citation Index) and CINAHL. Gaps arising from the database search will be addressed through snowballing, citation tracking and review of reference lists of systematic reviews of the PCMH. We will accept qualitative, quantitative and mixed methods primary research studies published in peer-reviewed publications. A stakeholder group will provide input to the review. DISCUSSION: The review will result in a refined theoretical framework that can be used by primary care practices to guide implementation of the PCMH. Narrative accompanying the refined framework will explain how the constructs (existing and added) work together to successfully implement the PCMH in primary care. The unpopulated CFIR constructs will be used to identify where further primary research may be needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021235960.

Intensive care unit strain and mortality risk in patients admitted from the ward in Australia and New Zealand.

PURPOSE: ICU strain (low number of available beds) may be associated with a delay and altered threshold for ICU admission and adverse patient outcomes. We aimed to investigate the impact of ICU strain on hospital mortality in critically ill patients admitted from wards across Australia and New Zealand. MATERIALS AND METHODS: Ward patient admitted to ICU and ICU bed data at 137 hospitals were accessed between January 2013 and December 2016. ICU strain was classified as low (≤0.5 patients admitted per available ICU bed in a 6-h block), medium (0.5 to ≤1) or high (>1). Logistic regression models were used to examine the relationship between ICU strain and hospital mortality. RESULTS: 57,844 ICU admissions were analysed, with the majority (64.4%) admitted to medium-strain ICUs. Those admitted to high-strain ICUs spent longer in hospital prior to ICU than medium-strain or low-strain ICUs. After adjusting for confounders those admitted to high-strain ICUs [OR 1.24 (95%CI 1.14-1.35)] or medium-strain ICUs [OR 1.18 (95%CI 1.09-1.27)], (p < 0.001) had a higher risk of death compared low-strain ICUs. CONCLUSION: ICU strain is associated with longer times in hospital prior to ICU admission and was associated with increased risk of death in patients admitted from ward.

Gap in funding for specialist hospitals treating patients with traumatic spinal cord injury under an activity-based funding model in New South Wales, Australia.

Objective The aim of this study was to estimate the difference between treatment costs in acute care settings and the level of funding public hospitals would receive under the activity-based funding model. Methods Patients aged ≥16 years who had sustained an incident traumatic spinal cord injury (TSCI) between June 2013 and June 2016 in New South Wales were included in the study. Patients were identified from record-linked health data. Costs were estimated using two approaches: (1) using District Network Return (DNR) data; and (2) based on national weighted activity units (NWAU) assigned to activity-based funding activity. The funding gap in acute care treatment costs for TSCI patients was determined as the difference in cost estimates between the two approaches. Results Over the study period, 534 patients sustained an acute incident TSCI, accounting for 811 acute care hospital separations within index episodes. The total acute care treatment cost was estimated at A$40.5 million and A$29.9 million using the DNR- and NWAU-based methods respectively. The funding gap in total costs was greatest for the specialist spinal cord injury unit (SCIU) colocated with a major trauma service (MTS), at A$4.4 million over the study period. Conclusions The findings of this study suggest a substantial gap in funding for resource-intensive patients with TSCI in specialist hospitals under current DRG-based funding methods. What is known about the topic? DRG-based funding methods underestimate the treatment costs at the hospital level for patients with complex resource-intensive needs. This underestimation of true direct costs can lead to under-resourcing of those hospitals providing specialist services. What does this paper add? This study provides evidence of a difference between true direct costs in acute care settings and the level of funding hospitals would receive if funded according to the National Efficient Price and NWAU for patients with TSCI. The findings provide evidence of a shortfall in the casemix funding to public hospitals under the activity-based funding for resource-intensive care, such as patients with TSCI. Specifically, depending on the classification system, the principal referral hospitals, the SCIU colocated with an MTS and stand-alone SCIU were underfunded, whereas other non-specialist hospitals were overfunded for the acute care treatment of patients with TSCI. What are the implications for practitioners? Although health care financing mechanisms may vary internationally, the results of this study are applicable to other hospital payment systems based on diagnosis-related groups that describe patients of similar clinical characteristics and resource use. Such evidence is believed to be useful in understanding the adequacy of hospital payments and informing payment reform efforts. These findings may have service redesign policy implications and provide evidence for additional loadings for specialist hospitals treating low-volume, resource-intensive patients.

Identifying Predictors of Higher Acute Care Costs for Patients With Traumatic Spinal Cord Injury and Modeling Acute Care Pathway Redesign: A Record Linkage Study.

STUDY DESIGN: Record linkage study using healthcare utilization and costs data. OBJECTIVE: To identify predictors of higher acute-care treatment costs and length of stay for patients with traumatic spinal cord injury (TSCI). SUMMARY OF BACKGROUND DATA: There are few current or population-based estimates of acute hospitalization costs, length of stay, and other outcomes for people with TSCI, on which to base future planning for specialist SCI health care services. METHODS: Record linkage study using healthcare utilization and costs data; all patients aged more than or equal to 16 years with incident TSCI in the Australian state of New South Wales (June 2013-June 2016). Generalized Linear Model regression to identify predictors of higher acute care treatment costs for patients with TSCI. Scenario analysis quantified the proportionate cost impacts of patient pathway modification. RESULTS: Five hundred thirty-four incident cases of TSCI (74% male). Total cost of all acute index episodes approximately AUD$40.5 (95% confidence interval [CI] ±4.5) million; median cost per patient was AUD$45,473 (Interquartile Range: $15,535-$94,612). Patient pathways varied; acute care was less costly for patients admitted directly to a specialist spinal cord injury unit (SCIU) compared with indirect transfer within 24 hours. Over half (53%) of all patients experienced at least one complication during acute admission; their care was less costly if they had been admitted directly to SCIU. Scenario analysis demonstrated that a reduction of indirect transfers to SCIU by 10% yielded overall cost savings of AUD$3.1 million; an average per patient saving of AUD$5,861. CONCLUSION: Direct transfer to SCIU for patients with acute TSCI resulted in lower treatment costs, shorter length of stay, and less costly complications. Modeling showed that optimizing patient-care pathways can result in significant acute-care cost savings. Reducing potentially preventable complications would further reduce costs and improve longer-term patient outcomes. LEVEL OF EVIDENCE: 3.

Assessing the impact of care pathways on potentially preventable complications and costs for spinal trauma patients: protocol for a data linkage study using cohort study and administrative data.

INTRODUCTION: Traumatic spinal cord injuries have significant consequences both for the injured individual and the healthcare system, usually resulting in lifelong disability. Evidence has shown that timely medical and surgical interventions can lead to better patient outcomes with implicit cost savings. Potentially preventable secondary complications are therefore indicators of the effectiveness of acute care following traumatic injury. The extent to which policy and clinical variation within the healthcare service impact on outcomes and acute care costs for patients with traumatic spinal cord injury (TSCI) in Australia is not well described. METHODS AND ANALYSIS: A comprehensive data set will be formed using record linkage to combine patient health and administrative records from seven minimum data collections (including costs), with an existing data set of patients with acute TSCI (Access to Care Study), for the time period June 2013 to June 2016. This person-level data set will be analysed to estimate the acute care treatment costs of TSCI in New South Wales, extrapolated nationally. Subgroup analyses will describe the associated costs of secondary complications and regression analysis will identify drivers of higher treatment costs. Mapping patient care and health service pathways of these patients will enable measurement of deviations from best practice care standards and cost-effectiveness analyses of the different pathways. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the New South Wales Population and Health Services Research Ethics Committee. Dissemination strategies include peer-reviewed publications in scientific journals and conference presentations to enable translation of study findings to clinical and policy audiences.

Measuring and reducing waiting times: a cross-national comparison of strategies.

We compare strategies to manage surgical waiting times in Australia, Canada, England, New Zealand, and Wales to give policy insights into those that are most effective. Most of these countries have allocated dedicated funding and set explicit waiting time targets. Of the five countries, England has achieved the most sustained improvement, linked to major funding boosts, ambitious waiting-time targets, and a rigorous performance management system. While supply-side strategies are used in all five countries, New Zealand and parts of Canada have also invested in demand-side strategies through the use of clinical criteria to prioritize access to surgery.

Public policy and private health insurance: distributional impact on public and private hospital usage.

OBJECTIVE: To study the effectiveness of recent private health insurance (PHI) reforms, in particular the 30% rebate and Lifetime Health Cover, in terms of their stated aim of reducing the load on public hospitals. METHODS: Combines the use of two new projection models - "Private Health Insurance" (PHI) and "New South Wales Hospitals" that use public and private hospital inpatient data from 1996-97 to 1999-2000, and NSW population and private health insurance coverage statistics. RESULTS: With the PHI reforms 15% fewer individuals would use public hospitals in 2010 than without these reforms (around 18% fewer among the 40% most affluent Australians and 9% among the 40% least affluent). Lower public hospital usage would mainly be due to Lifetime Health Cover. CONCLUSION: If the PHI reforms remain in place, in 2010 a significant proportion of hospital use would be redirected away from the public sector and towards the private sector, with the shift being greatest among better-off Australians.

Hospital admissions by socio-economic status: does the 'inverse care law' apply to older Australians?

OBJECTIVE: To investigate whether the 'inverse care law' applies to New South Wales (NSW) hospital admissions--especially to older people with high socio-economic status (SES). DESIGN: Cross-sectional study analysing inequalities in public and private hospital admission rates by SES, defined in terms of age, sex and family income/size at the small geographic area level. SETTING: Admissions to NSW public and private hospitals in 1999-2000 (1.8 million admissions against a NSW population of 6.4 million). METHODOLOGY: Inequalities in hospitalisation rates were expressed as rate ratios across the most and least disadvantaged 20% of the NSW population. RESULTS: Public hospital admission rates for people aged 0-60 years were 24-35% higher for the most disadvantaged 20% of the NSW population than for the least disadvantaged 20%. For 70+ year-olds the direction of this difference was reversed--being 14% lower for the most disadvantaged 20% of the population (5% higher for public patients). For private hospitals this reversal prevailed for all age groups (23-49% lower). For all hospitals it was 16% and 27% lower for 60-69 and 70+ year-olds respectively, with higher admission rates for top SES 60+ year-olds most pronounced for renal dialysis, chemotherapy, colonoscopies and other diagnostic scopes, rehabilitation and follow-up, and cataract operations. CONCLUSION: While the 'inverse care law' did apply to 60+ year-olds, it did not apply either to younger NSW hospital users or to public patients in public hospitals. IMPLICATIONS: Awareness of these SES-level differentials should result in greater equality of access to hospital services, especially by older people.