Moving from Interest to Engagement-Understanding the Research Capacity Building Needs of Rehabilitation Doctors.

INTRODUCTION: Doctors working in rehabilitation settings have specialized clinical skills and experience, but research activity may be constrained by time pressures and inadequate current skills. This means missed opportunities to contribute to the evidence-base for better clinical practice and outcomes for people living with disabling, chronic complex conditions. This research aimed to understand rehabilitation doctors' research needs, experience, and aspirations to enable future training initiatives that are tailored to their practice context. METHODS: This exploratory sequential mixed-method study comprised a survey followed by focus groups. Rehabilitation doctors from three health services in south-east Queensland, Australia completed an online survey incorporating the Research Spider to explore their research experience, confidence, interest, opportunity, and intent. Focus groups explored the survey results and participants' views regarding strategies to build research capacity. RESULTS: The major findings were the gap between high research interest and low experience, confidence and opportunity; and fundamental research skills were identified as priority training topics. These findings support previous research. However, rehabilitation doctors may also have a self-expectation that, as competent clinicians, they should necessarily also be research-competent, and hold misperceptions regarding the shared nature of health services research. DISCUSSION: Protected time and funding may enhance engagement with research to generate specialty-relevant evidence for practice. To this end, a research capacity building initiative in the form of a series of self-directed learning packages has been developed and implemented. A tailored workshop to strengthen rehabilitation doctors' research skills and engagement has also been developed for implementation.

Use and cost of Medicare Benefits Schedule and Pharmaceutical Benefits Scheme services following inpatient rehabilitation for acquired disability in Australia.

Objectives This study explored publicly funded health system and patient expenditure in the post-acute phase following discharge from inpatient acquired brain injury (ABI) or spinal cord injury (SCI) rehabilitation. The secondary aim was to explore sociodemographic and injury characteristics associated with high costs. Methods This was a prospective cohort study. 153 patients (ABI: n = 85; SCI: n = 68) who consented to the use of their Medicare data were recruited between March 2017 and March 2018, at the point of discharge from ABI or SCI specialist rehabilitation units. The main outcome measure involved linkage of the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data for the 12 months following discharge from rehabilitation. Bayesian penalised regression was used to determine characteristics associated with high costs. Results The median number of MBS items used in the 12 months after discharge was 33 (IQR: 21-52). General practitioners and allied health services were accessed by 100% and 41% of the cohort, respectively. The median MBS system cost (in Australian dollars) was $2006 (IQR: $162-$3090). Almost half (46%) of the participants had no MBS patient expenditure. The median PBS system cost was $541 (IQR: $62-$1574). For people with ABI, having a traumatic injury or one comorbidity was associated with lower PBS system costs by on average $119 and $134, respectively. We also found that hospitalisation in ABI was associated with higher PBS system costs, by on average $669. Conclusion There was evidence of high and variable MBS and PBS costs, raising concerns about financial hardship. Future research should focus on identifying any unmet service and prescription needs in the post-acute rehabilitation phase for these populations.

Perceived service adequacy and unmet need after discharge from brain injury rehabilitation.

PURPOSE: The present study aimed to quantify the perceived needs and adequacy of realised access to post-acute services in a sample of people with acquired brain injury in the first 6-months after discharge from inpatient rehabilitation. A secondary focus was the influence of access to funding and specialist transitional rehabilitation on unmet needs. MATERIALS AND METHODS: Participants were 51 adults with a median age of 50 (IQR 35-57) recruited from an inpatient rehabilitation unit in an Australian tertiary hospital. The sample was those who had an acquired brain injury, including 23 who sustained a traumatic injury and 28 who sustained a non-traumatic injury. Measures were collected via telephone at 3- and 6-months, in a prospective observational cohort design using the Needs and Provisions Complexity Scale. A series of logistic regression models were used to determine the effects of participation in a transitional rehabilitation program and funding pathway on adequacy and unmet needs. RESULTS: Unmet needs for rehabilitation were most commonly reported (60%), followed by unmet needs in relation to health care (40%), social care (35%), personal care (32%) and environment-related (14%). Participants who attended transitional rehabilitation were more likely to indicate unmet health care needs (OR = 6.40, 95% CI = 1.40-29.24, p = 0.02). CONCLUSIONS: The study highlights the need to look beyond functional impairment when conceptualising appropriate access. Additionally, the present research highlighted the need for greater work into an expectation of services.IMPLICATIONS FOR REHABILITATIONThe majority of people with an acquired brain injury report unmet needs at 6 months post discharge.Present findings support the utility of patient reported measures when considering treatment evaluation with people with ABI, where assessing the personal appraisal of individuals needs may prove to be a key indicator to facilitate optimal service access.There are specific services that needed and not provided including psychological, speech pathology, family carer needs and vocational rehabilitation, and therefore are a key target for ensuring appropriate support is provided.

Healthcare services for people with acquired disability in South-East Queensland, Australia: Assessing potential proximity and its association with service obstacles.

This study described access potential in South-East Queensland, to healthcare services commonly used by people with acquired disability; and investigated the association between service proximity and perceived service obstacles. First, we described accessibility by conducting a spatial analysis to create maps of potential accessibility to health services in South-East Queensland. Queensland statistical area level 2 (SA2) locations were combined with the residential locations of participants from a longitudinal cohort study involving people with ABI and SCI. The locations of selected health services of interest were identified from Health Direct's National Health Service Directory. Travel times via motor vehicle were modelled with Robust Gaussian Stochastic Process, to smoothly interpolate between the sparse time-to-service observations. Probabilistic predicted values were generated from the model and were used to construct service accessibility maps of South-East Queensland. Disability population data were used to identify SA2s with relatively low service access but a high disability population. Second, we examined perceived service obstacles, by investigating the relationship between potential access to services and perceived service obstacles was examined using data from 63 people with ABI or SCI discharged from the specialist state-wide rehabilitation services, located in South-East Queensland. Obstacles to accessing service in relation to resource availability, transportation and finances were collected three-months after discharge, using the Service Obstacle Scale. Travel times to the closest health service were computed for each individual and were compared to their Service Obstacle Scale responses. Access potential was highly variable, particularly for allied health services. We identified several low-access, high-disability population areas. These hotpots of poor access were generally to the north and west of greater Brisbane. Longer travel times to allied health services were associated with 260% higher odds of agreeing that resource availability was an obstacle to accessing services. Policy makers should be concerned with the hotspots of poor access identified.

Planning with care complexity: Factors related to discharge delays of hospitalised people with disability.

Planning for discharge and supports beyond hospital for people with disability in Australia involves negotiation of complex care systems. The aims of this study were to examine how the individualised support pathway of the National Disability Insurance Scheme (NDIS) functioned for admitted people with disability who required funded support to leave hospital; and to explore the factors indicative of increased care complexity associated with delays. Retrospective chart reviews of people with disability were conducted. Data on 198 eligible patients were extracted, including NDIS plan approval and plan implementation timeframes and discharge delay. Participants' median age was 52 years (interquartile range = 41-59). The most common disability type was spinal cord injury (41%). The median NDIS plan approval and implementation timeframes were 89 days (63-123) and 39 days (8-131), respectively, and most participants (72%) experienced a delayed discharge. A longer plan implementation timeframe was associated with higher odds of a delay in discharge (OR = 3.41, 95% credible interval = 1.56, 7.11). We did not find any evidence that plan approval timeframe, or any other variable indicative of increased care complexity, was associated with discharge delays. Our findings suggest that a delayed discharge will likely be the reality for people with disability who require funded supports to leave hospital. They also suggest that NDIS plan implementation is a major challenge and a focus for policy and practice improvements. To target solutions, further research should focus on the interactions and negotiations of the multiple intermediaries involved and resource and structural impediments to plan implementation.

Where to next? An exploration of patients with disability and complex needs who leave acute care hospitals via an interim discharge pathway.

Objective To examine the characteristics and circumstances of admitted patients with disability who require individualised supports to leave hospital and who experience interim discharge arrangements. Methods The study used a retrospective exploratory design. Medical chart reviews of patients with disability who required funded support to leave hospital were conducted. The records of 224 patients admitted to one of three hospital facilities in South-East Queensland, Australia, between May 2017 and January 2020 were reviewed. Information about hospital facility, demographic characteristics, disability type, support needs, discharge destination, and reasons for interim discharges were extracted for analysis. Results Forty of 224 patients were discharged to an interim destination. Inter-hospital transfers were the most common interim discharge arrangement. Being divorced or separated was the only demographic variable associated with having an interim discharge arrangement for admitted patients with disability. More patients with disability who experienced an interim discharge required accommodation supports and behavioural supports compared to patients who were not involved in interim discharges. Conclusions Patients with disability with minimal informal support and who rely on a sophisticated mix of individualised supports to leave hospital may be more susceptible to interim discharge arrangements. Early identification of these patients and formal mechanisms for ensuring continuous coordination of ongoing transitions and supports is critical to avoid sub-optimal outcomes. Future research is needed to capture a complete picture of the series of transitions of interim discharged patients with disability leaving acute care facilities and the quality of their supports and outcomes.

The influence of personal factors, unmet need and service obstacles on the relationship between health service use and outcome after brain injury.

BACKGROUND: This exploratory study aimed to: (i) examine the relationship between health service use and quality of life, psychological wellbeing, global function and participation after discharge from brain injury inpatient rehabilitation, and (ii) determine the influence of personal factors, unmet need for services and service obstacles on the relationship between service use and these outcomes. METHODS: Using a prospective cohort design, 41 adults with acquired brain injury (median age = 46 years; 71% male; 61% severe traumatic injury) were followed for 6-months after discharge from specialist brain injury inpatient rehabilitation. Service use was continuously recorded and obtained through data linkage methods, focusing on the use of: outpatient medical services, outpatient nursing, outpatient allied health; medical acute services; incidents of re-hospitalization; and transitional rehabilitation service use. Outcome questionnaire measures were completed via telephone, at 6-months after discharge, and included: the EuroQol-5D; Depression Anxiety and Stress Scale, Mayo-Portland Adaptability Inventory and Sydney Psychosocial Reintegration Scale. Data were analyzed in a heterogeneous treatment effects framework, using Bayesian Additive Regression Trees. RESULTS: There was weak evidence that transitional rehabilitation service use was associated with better psychological wellbeing scores. The posterior probability of lower depression, anxiety and stress scores was .87, .81 and .86, respectively (average treatment effect). There was also weak evidence that re-hospitalization was associated with worse independent living skills scores. The posterior probability of worse scores was .87. However, most re-hospitalizations were due to unavoidable medical complications. We did not find that place of residence at discharge, marital status, unmet need, or service obstacles affected the relationship between service use and the studied outcomes. CONCLUSIONS: This study may highlight the importance of participation in transitional rehabilitation, in the 6-months after discharge from brain injury rehabilitation. Replication in a larger sample size is required to confirm these findings.

The effect of access to a designated interdisciplinary post-acute rehabilitation service on participant outcomes after brain injury.

OBJECTIVE: This study aimed to determine the influence of participation in a designated acquired brain injury (ABI) transitional rehabilitation service (ABI TRS) on outcome, in the context of a historical comparison group (HIST). Design: A cohort study, with retrospective comparison. Participants: 187 persons with ABI. Measures: The Depression, Anxiety and Stress Scale (DASS-21), Mayo-Portland Adaptability Index (MPAI-4) and Sydney Psychosocial and Reintegration Scale (SPRS) were completed at discharge and 3 months after discharge. Participation in the ABI TRS involved interdisciplinary rehabilitation, 2-4 times per week, for 3 months after hospital discharge. Results: There was evidence that at 3 months, participants with ABI TRS showed stabilized psychological wellbeing, and improvements in MPAI-4 ability and participation scores; in addition to improvements in SPRS occupational activity and living skills scores. Conclusion: A designated ABI TRS may improve the transition from hospital to home, and could form an important part of the brain injury rehabilitation continuum, between the inpatient and community setting.

The Effect of Health Service Use, Unmet Need, and Service Obstacles on Quality of Life and Psychological Well-Being in the First Year After Discharge From Spinal Cord Injury Rehabilitation.

OBJECTIVE: This study examined the effects of health and rehabilitation service use, unmet need for services, and service obstacles on health-related quality of life (HR QoL) and psychological well-being after discharge from spinal cord injury (SCI) rehabilitation. DESIGN: Prospective cohort study, with participants followed up at 6 and/or 12 months after discharge from SCI inpatient rehabilitation. SETTING: Community setting. PARTICIPANTS: People with SCI (N=55; mean age 51y; 76.4% men; 61.8% traumatic injury; mean length of stay 137d). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Service Usage Scale, Service Obstacles Scale, the EuroQol-5D, and the Depression Anxiety and Stress Scale short form. Eight predictors of outcome were considered: service use (ie, use of general practitioner, medical specialist, nursing, and allied health, and rehospitalization), unmet need, and service obstacles (ie, finances and transport). Possibly important predictors of each outcome were identified via penalized regression, and a final model was fit using Bayesian hierarchical regression with a Gaussian or zero-inflated Poisson response distribution. RESULTS: Financial obstacles were associated with a poorer HR QoL (ß [95% credible interval]= -0.095 [-0.166 to -0.027]) and higher anxiety (odds ratio, OR [95% credible interval]=1.63 [1.16-2.23]). Rehospitalization was associated with a lower EuroQol visual analog scale (ß= -11.2 [-19.7 to -2.5]) and, interestingly, lower anxiety (OR=1.63 [1.16-2.23]). Use of allied health was associated with higher anxiety (OR=2.48 [1.42-4.44]). CONCLUSION: The varying degrees of financial hardship experienced after injury with complex rehabilitation needs requires investigation, as does the interactive effects of service use, unmet need, and service obstacles on outcomes like QoL and psychological well-being.

General practitioners' considerations when deciding whether to initiate end-of-life conversations: a qualitative study.

BACKGROUND: End-of-life discussions often are not initiated until close to death, even in the presence of life-limiting illness or frailty. Previous research shows that doctors may not explicitly verbalize approaching end-of-life in the foreseeable future, despite shifting their focus to comfort care. This may limit patients' opportunity to receive information and plan for the future. General Practitioners (GPs) have a key role in caring for increasing numbers of patients approaching end-of-life. OBJECTIVE: To explore GPs' thought processes when deciding whether to initiate end-of-life discussions. METHODS: A qualitative approach was used. We purposively recruited 15 GPs or GP trainees from South-East Queensland, Australia, and each participated in a semi-structured interview. Transcripts were analyzed using inductive thematic analysis. RESULTS: Australian GPs believe they have a responsibility to initiate end-of-life conversations, and identify several triggers to do so. Some also describe caution in raising this sensitive topic, related to patient, family, cultural and personal factors. CONCLUSIONS: These findings enable the development of approaches to support GPs to initiate end-of-life discussions that are cognizant both of GPs' sense of responsibility for these discussions, and factors that may contribute to caution initiating them, such as anticipated patient response, cultural considerations, societal taboos, family dynamics and personal challenges to doctors.

General practitioners' practical approach to initiating end-of-life conversations: a qualitative study.

BACKGROUND: As doctors who provide care across the life-course, general practitioners (GPs) play a key role in initiating timely end-of-life discussions. Nonetheless, these discussions are often not initiated until close to death. Given the ageing of the population, GPs will be confronted with end-of-life care more often, and this needs to become a core skill for all GPs. OBJECTIVE: To describe GPs' approach to initiating end-of-life discussions. METHODS: Fifteen GPs or GP trainees from South-East Queensland, Australia, were purposively recruited to participate in a semi-structured interview. We analysed transcripts using a thematic analysis. RESULTS: GPs' approach to initiating end-of-life discussions was summarized by four themes: (1) Preparing the ground; (2) finding an entry point; (3) tailoring communication and (4) involving the family. CONCLUSIONS: Emphasis on the doctor-patient relationship; assessing patient readiness for end-of-life discussions; and sensitive information delivery is consistent with factors previously reported to be important to both GPs and patients in this context. Our findings provide a framework for GPs initiating end-of-life discussions, which must be tailored to patient and GP personality factors. Further research is required to evaluate its outcomes.

A qualitative follow-up study of diabetes patients' appraisal of an integrated diabetes service in primary care.

As the prevalence of type 2 diabetes continues to escalate, health system reform is seeking better patient outcomes through new models of care that aim to provide the most appropriate care when needed. Patients' experiences of service innovations can shed light on the successes and challenges of implementing change. This paper explores patients' views of a new model of integrated care for patients with type 2 diabetes. A mixed-methods, randomised control trial evaluated a beacon clinic model of care for complex type 2 diabetes led by specialist general practitioners (GPs) in primary care settings in Brisbane, Australia. In this qualitative sub-study conducted between May 2014 and January 2015, 25 consenting participants were re-interviewed after 12 months using semi-structured questions, to explore their experiences of the new model of care. Interview transcripts were analysed thematically. In the first theme, Organised for patient-centred care, patients appraised the structural elements of the clinic. For most, it was an enabling experience which included convenience, flexibility and prompt communication back to the referring GPs. The preferences of a minority were partly realised, as they tried to understand the clinical purpose in comparison with traditional care. The second theme, Positioned as partners in care, revealed the pivotal role of patient-clinician relationships in patients' engagement with advice and self-care. Most found clinicians' collaborative approach engaging and motivating. A small minority with contextual concerns were disappointed with the focus on diabetes and struggled to engage fully with the model. Most participants valued this model of care, which reflects a capacity to manage the variable and complex needs of most patients referred for care. However, multi-level strategies are also needed to enhance patients' engagement with care and the sustainability of integrated diabetes care.

A multifaceted intervention to reduce inappropriate polypharmacy in primary care: research co-creation opportunities in a pilot study.

Co-creation (or co-design) represents the highest form of stakeholder engagement, but it can be infeasible to co-create with all stakeholders through all stages of a research project. The choice of stakeholders for co-design will depend on the study purpose and context of change. For this deprescribing pilot study, general practitioners were recognised as a critical gateway for co-creation, with patients' perspectives of the deprescribing process to be assessed in the evaluation of the pilot.

Challenges of user-centred assistive technology provision in Australia: shopping without a prescription.

PURPOSE: People with disability have a right to assistive technology devices and services, to support their inclusion and participation in society. User-centred approaches aim to address consumer dissatisfaction and sub-optimal outcomes from assistive technology (AT) provision, but make assumptions of consumer literacy and empowerment. Policy discourses about consumer choice prompt careful reflection, and this paper aims to provide a critical perspective on user involvement in assistive technology provision. METHODS: User-centred approaches are considered, using literature to critically reflect on what user involvement means in AT provision. Challenges at the level of interactions between practitioners and consumers, and also the level of markets and policies are discussed, using examples from Australia. RESULTS: There is no unanimous conceptual framework for user-centred practice. Power imbalances and differing perspectives between practitioners and consumers make it difficult for consumers to feel empowered. Online access to information and international suppliers has not surmounted information asymmetries for consumers or lifted the regulation of publicly funded AT devices. CONCLUSIONS: Ensuring access and equity in the public provision of AT is challenging in an expanding market with diverse stakeholders. Consumers require personalised information and support to facilitate their involvement and choice in AT provision. Implications for Rehabilitation Variations in approaches informing AT provision practices have a profound impact on equity of access and outcomes for consumers. An internationalised and online market for AT devices is increasing the need for effective information provision strategies and services. Power imbalances between practitioners and consumers present barriers to the realisation of user-centred practice.

Making sense of change: patients' views of diabetes and GP-led integrated diabetes care.

BACKGROUND: Health system reform is directed towards better management of diabetes. However, change can be difficult, and patients' perspectives are a key aspect of implementing change. OBJECTIVE: This study investigated patients' perceptions and experiences of type 2 diabetes (T2DM), self-care and engagement with GP-led integrated diabetes care. DESIGN: Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care. Normalization process theory was used to orientate the thematic analysis, to explain the work of implementing change. SETTING: Two specialist GP-based complex diabetes services in primary care in Brisbane, Australia. PARTICIPANTS: Intervention group patients (n = 30) in a randomized controlled trial to evaluate a model of GP-led integrated care for complex T2DM. MAIN OUTCOME MEASURES: Participants' experiences and perceptions of diabetes management and a GP-led model of care. RESULTS: Three themes were identified: sensibility of change, 'diabetic life' and diabetes care alliance. The imperative of change made sense, but some participants experienced dissonance between this rational view and their lived reality. Diabetes invaded life, revealing incongruities between participants' values and living with diabetes. They appreciated a flexible and personalized approach to care. DISCUSSION: Participants responded to advice in ways that seemed rational within the complexities of their life context. Their diabetes partnerships with health professionals coupled providers' biomedical expertise with patients' contextual expertise. CONCLUSIONS: Learning to manage relationships with various health professionals adds to patients' diabetes-related work. Providers need to adopt a flexible, interactive approach and foster trust, to enable better diabetes care.

'The onus is on me': primary care patient views of Medicare-funded team care in chronic disease management in Australia.

BACKGROUND AND OBJECTIVE: This study investigated the views of primary care patients in receipt of Medicare-funded team care for chronic disease management (CDM) in Australia. DESIGN: A qualitative study using a repeat in-depth interview design. PARTICIPANTS AND SETTING: Twenty-three patients (17 female), aged 32-89, were recruited over a six-month period from two purposively selected general practices: one urban and one regional practice in Queensland, Australia. DATA COLLECTION PROCEDURE: Semi-structured interviews were conducted with participants 6 months apart. An interview guide was used to ensure consistency of topics explored. Interviews were recorded and transcribed, and a thematic analysis was conducted. RESULTS: Patients in this study viewed the combined contributions of a GP and other health professionals in team care as thorough and reassuring. In this case of Medicare-funded team care, patients also saw obligations within the structured care routine which cultivated a personal ethics of CDM. This was further influenced by how patients viewed their role in the health-care relationship. Aside from personal obligations, Medicare funding got patients engaged in team care by providing financial incentives. Indeed, this was a defining factor in seeing allied health professionals. However, team care was also preferential due to patients' valuations of costs and benefits. CONCLUSION: Patients are likely to engage with a structured team care approach to CDM if there is a sense of personal obligation and sufficient financial incentive. The level of engagement in team care is likely to be optimized if patient expectations and preferences are considered in decisions.

A new model of integrated primary-secondary care for complex diabetes in the community: study protocol for a randomised controlled trial.

BACKGROUND: A new model of complex diabetes care is provided by a multidisciplinary team which incorporates general practitioner (GP) Clinical Fellows supported by an Endocrinologist and diabetes educator within a community-based general practice setting. This study evaluates the health and clinical benefits of the new model of care, assesses the acceptability of the model to patients, GPs and other health professionals, and examines the cost-effectiveness of the model. METHODS/DESIGN: The study is an open, non-inferiority randomised controlled trial with data collected at baseline, 6 and 12 months. Participants are identified from new patients on hospital-based diabetes outpatient clinic waiting lists and new GP referrals. Eligible consenting patients are randomised to either a community practice site (intervention) or a hospital site (usual care). In the intervention model, medical care is led by a GP Clinical Fellow in partnership with an Endocrinologist. Quantitative measures include clinical indicators with HbA1c as the primary outcome; patient-reported outcomes include health-related quality of life, mental health and satisfaction with care. Qualitative methods will be used to explore the perspectives and experiences of patients and providers regarding the new model of care. An economic evaluation will also be undertaken. DISCUSSION: This model of care seeks to improve the quality and safety of healthcare at the interface between the hospital and primary care sectors for patients with complex diabetes. The study will provide empirical evidence about the impact of the model of care on health outcomes, patient and clinician satisfaction, as well as any economic impacts. TRIAL REGISTRATION: Clinical Trials Registry Number: ACTRN12612000380897.

Social processes that can facilitate and sustain individual self-management for people with chronic conditions.

Recent shifts in health policy direction in several countries have, on the whole, translated into self-management initiatives in the hope that this approach will address the growing impact of chronic disease. Dominant approaches to self-management tend to reinforce the current medical model of chronic disease and fail to adequately address the social factors that impact on the lives of people with chronic conditions. As part of a larger study focused on outcomes following a chronic disease, this paper explores the processes by which a chronic disease self-management (CDSM) course impacted on participants. Five focus groups were conducted with participants and peer leaders of the course in both urban and rural regions of Queensland, Australia. The findings suggested that outcomes following CDSM courses depended on the complex interplay of four social factors, namely, social engagement, the development of a collective identity, the process of building collaborative coping capacity, and the establishment of exchange relationships. This study highlights the need for an approach to self-management that actively engages consumers in social relationships and addresses the context within which their lives (and diseases) are enacted. This approach extends beyond the psychoeducational skills-based approach to self-management into a more ecological model for disease prevention.

Investing in big ideas: utilisation and cost of Medicare Allied Health services in Australia under the Chronic Disease Management initiative in primary care.

OBJECTIVE: To critically examine utilisation of the 13 allied health services provided through Medicare Chronic Disease Management program and related general practitioner (GP) care planning initiatives. METHODS: Statistics generated from national billing data from July 2005 to June 2009 were extracted from Medicare data and compared by profession, State or Territory and population. RESULTS: Most services grew over 4 years although nationally consistent service levels were not found for any allied health provider profession. On referral from GPs, podiatry, physiotherapy and dietetics provided most services (82%) in 2008-09. Professions had unique patterns of referral instanced by age range and sex of clientele. Wide variation was apparent in per capita utilisation of allied health services by State or Territory; some with far less than average national use and others with high use. Annual number of GP Management Plans or Team Care Arrangements was low (mean: ≤22 per GP in 2008-09), indicating low use of care planning. CONCLUSION: Inequality of accessibility for patients was apparent. Five years into the program, a review of Medicare Allied Health CDM policy is warranted. Implications. Research and evaluation is needed to identify whether the program is meeting the needs of GPs, allied health providers and chronic disease patients.