Implementation of a primary-tertiary shared care model to improve the detection of familial hypercholesterolaemia (FH): a mixed methods pre-post implementation study protocol.

INTRODUCTION: Familial hypercholesterolaemia (FH) is an autosomal dominant inherited disorder of lipid metabolism and a preventable cause of premature cardiovascular disease. Current detection rates for this highly treatable condition are low. Early detection and management of FH can significantly reduce cardiac morbidity and mortality. This study aims to implement a primary-tertiary shared care model to improve detection rates for FH. The primary objective is to evaluate the implementation of a shared care model and support package for genetic testing of FH. This protocol describes the design and methods used to evaluate the implementation of the shared care model and support package to improve the detection of FH. METHODS AND ANALYSIS: This mixed methods pre-post implementation study design will be used to evaluate increased detection rates for FH in the tertiary and primary care setting. The primary-tertiary shared care model will be implemented at NSW Health Pathology and Sydney Local Health District in NSW, Australia, over a 12-month period. Implementation of the shared care model will be evaluated using a modification of the implementation outcome taxonomy and will focus on the acceptability, evidence of delivery, appropriateness, feasibility, fidelity, implementation cost and timely initiation of the intervention. Quantitative pre-post and qualitative semistructured interview data will be collected. It is anticipated that data relating to at least 62 index patients will be collected over this period and a similar number obtained for the historical group for the quantitative data. We anticipate conducting approximately 20 interviews for the qualitative data. ETHICS AND DISSEMINATION: Ethical approval has been granted by the ethics review committee (Royal Prince Alfred Hospital Zone) of the Sydney Local Health District (Protocol ID: X23-0239). Findings will be disseminated through peer-reviewed publications, conference presentations and an end-of-study research report to stakeholders.

Assessing the reach and safety of an innovative urgent care service tailored to older adults.

Traditional emergency departments (EDs) are overcrowded and sometimes not suitable for older adults with complex needs. Specialised geriatric urgent care pathways for selected patients can alleviate ED demand and improve patient experience. To address urgent care needs for older adults in Southern Adelaide, the Complex And RestorativE (CARE) service was established. CARE offers alternative, geriatrician-led treatment pathways consisting of a ward-based treatment centre and an in-home visiting team called Eyes on Scene (EoS). Both pathways offer medical, nursing and allied health treatment. Routinely collected clinical data were analysed to explore the reach of the service and the incidence and nature of adverse events. Between September 2021 and March 2023, the CARE service attended to 5324 older adults requiring urgent care. A significant proportion of patients were discharged to or remained in their regular place of residence, with few requiring inpatient admissions or referrals to other facilities. A total of 7% of patients required transfer to ED and adverse events were rare. The CARE service demonstrates a feasible and safe alternative model of urgent care for older Australians.

Local Level Economic Evaluation: What is it? What is its Value? Is it Sustainable?

In Australia, local health services with allocated budgets manage public hospital services for defined geographical areas. The authors were embedded in a local health service for around 2 years and undertook a range of local level economic evaluations for which three decision contexts were defined: intervention development, post-implementation and prioritisation. Despite difficulties in estimating opportunity costs and in the relevance of portfolio-based prioritisation approaches, economic evaluation added value to local decision-making. Development-focused (ex ante) economic evaluations used expert elicitation and calibration methods to synthesise published evidence with local health systems data to evaluate interventions to prevent hospital acquired complications. The use of economic evaluation facilitated the implementation of interventions with additional resource requirements. Decision analytic models were used alongside the implementation of larger scale, more complex service interventions to estimate counterfactual patient pathways, costs and outcomes, providing a transparent alternative to the statistical analyses of intervention effects, which were subject to high risk of bias. Economic evaluations of more established services had less impact due to data limitations and lesser executive interest. Prioritisation-focused economic evaluations compared costs, outcomes and processes of care for defined patient populations across alternative local health services to identify, understand and quantify the effects of unwarranted variation to inform priority areas for improvement within individual local health services. The sustained use of local level economic evaluation could be supported by embedding health economists in local continuous improvement units, perhaps with an initial focus on supporting the development and evaluation of prioritised new service interventions. Shared resources and critical mass are important, which could be facilitated through groups of embedded economists with joint appointments between different local health services and the same academic institution.

Implementation of consensus-based perioperative care pathways to reduce clinical variation for elective surgery in an Australian private hospital: a mixed-methods pre-post study protocol.

INTRODUCTION: Addressing clinical variation in elective surgery is challenging. A key issue is how to gain consensus between largely autonomous clinicians. Understanding how the consensus process works to develop and implement perioperative pathways and the impact of these pathways on reducing clinical variation can provide important insights into the effectiveness of the consensus process. The primary objective of this study is to understand the implementation of an organisationally supported, consensus approach to implement perioperative care pathways in a private healthcare facility and to determine its impact. METHODS: A mixed-methods Effectiveness-Implementation Hybrid (type III) pre-post study will be conducted in one Australian private hospital. Five new consensus-based perioperative care pathways will be developed and implemented for specific patient cohorts: spinal surgery, radical prostatectomy, cardiac surgery, bariatric surgery and total hip and knee replacement. The individual components of these pathways will be confirmed as part of a consensus-building approach and will follow a four-stage implementation process using the Exploration, Preparation, Implementation and Sustainment framework. The process of implementation, as well as barriers and facilitators, will be evaluated through semistructured interviews and focus groups with key clinical and non-clinical staff, and participant observation. We anticipate completing 30 interviews and 15-20 meeting observations. Administrative and clinical end-points for at least 152 participants will be analysed to assess the effectiveness of the pathways. ETHICS AND DISSEMINATION: This study received ethical approval from Macquarie University Human Research Ethics Medical Sciences Committee (Reference No: 520221219542374). The findings of this study will be disseminated through peer-reviewed publications, conference presentations and reports for key stakeholders.

Process mining for healthcare decision analytics with micro-costing estimations.

Managing constrained healthcare resources is an important and inescapable role of healthcare decision makers. Allocative decisions are based on downstream consequences of changes to care processes: judging whether the costs involved are offset by the magnitude of the consequences, and therefore whether the change represents value for money. Process mining techniques can inform such decisions by quantitatively discovering, comparing and detailing care processes using recorded data, however the scope of techniques typically excludes anything 'after-the-process' i.e., their accumulated costs and resulting consequences. Cost considerations are increasingly incorporated into process mining techniques, but the majority of healthcare costs for service and overhead components are commonly apportioned and recorded at the patient (trace) level, hiding event level detail. Within decision-analysis, event-driven and individual-level simulation models are sometimes used to forecast the expected downstream consequences of process changes, but are expensive to manually operationalise. In this paper, we address both of these gaps within and between process mining and decision analytics, by better linking them together. In particular, we introduce a new type of process model containing trace data that can be used in individual-level or cohort-level decision-analytical model building. Furthermore, we enhance these models with process-based micro-costing estimations. The approach was evaluated with health economics and decision modelling experts, with discussion centred on how the outputs could be used, and how similar information would otherwise be compiled.

The 2021 proposal to increase market forces in the Australian residential aged-care sector.

In Australia, the US and Europe, policy makers use markets to incentivise aged care providers to produce greater quality care. The Australian Government announced in 2021 that it would further increase market forces in residential aged care to improve quality. The proposals respond to poor quality found within residential aged care, with overuse of psychotropic medications and physical constraints, social isolation and neglect. This paper outlines the market-orientated reforms the Government seeks to implement, including the policy development pathway over the last two decades. It refers to a theoretical model of provider behaviour under administered prices, and empirical research on the impact of similar market-orientated reforms delivered elsewhere, to highlight the reforms' strengths, weaknesses, and potential market outcomes. This paper concludes by identifying additional reforms that could better incentivise care quality and offers lessons to countries that have sought to marketise their nursing home care sectors.

Improving mental health and social participation outcomes in older adults with depression and anxiety: Study protocol for a randomised controlled trial.

BACKGROUND: Increasing both the frequency and quality of social interactions within treatments for anxiety and depressive disorders in older adults may improve their mental health outcomes and quality of life. This study aims to evaluate the clinical efficacy and cost utility of an enhanced cognitive behavioural therapy (CBT) plus social participation program in a sample of older adults with depression and/or anxiety. METHODS: A total of 172 community-dwelling adults aged 65 years or older with an anxiety and/or depressive disorder will be randomly allocated to either an enhanced CBT plus social participation program (n = 86) or standard CBT (n = 86). Both treatments will be delivered during 12 weekly individual sessions utilising structured manuals and workbooks. Participants will be assessed at pre-treatment, post-treatment, and 12-month follow-up. The primary outcome evaluates mean change in clinician-rated diagnostic severity of anxiety and depressive disorders from baseline to post-treatment (primary endpoint) based on a semi-structured diagnostic interview. Secondary outcomes evaluate changes in symptomatology on self-report anxiety and depression measures, as well as changes in social/community participation, social network, and perceived social support, loneliness, quality of life, and use of health services. Economic benefits will be evaluated using a cost-utility analysis to derive the incremental cost utility ratios for the enhanced CBT program. DISCUSSION: Outcomes from this study will provide support for the establishment of improved psychosocial treatment for older adults with anxiety and/or depression. Study outcomes will also provide health systems with a clear means to reduce the impact of poor emotional health in older age and its associated economic burden. In addition to the empirical validation of a novel treatment, the current study will contribute to the current understanding of the role of social participation in older adult wellbeing. TRIAL REGISTRATION: Prospectively registered on the Australian New Zealand Clinical Trials Registry (ID: ACTRN12619000242123; registered 19th February 2019) and the ISRCTN registry (ID: ISRCTN78951376; registered 10th July 2019).

Access, Use, and Patient-Reported Experiences of Emergency Care During the COVID-19 Pandemic: Population-Based Survey.

BACKGROUND: An increase in the number of people presenting to emergency departments (EDs) is contributing to ED overcrowding. In the early stages of the COVID-19 pandemic, there was a significant reduction in the number of ED presentations in Australia, creating an opportunity to learn from patients' experiences of alternative management options. OBJECTIVE: The aim of this study is to report on the use and experience of health services by Australian adults experiencing a health issue during the COVID-19 pandemic for which they would have presented at an ED prior to the pandemic. METHODS: An online survey was conducted in May 2020. Reported health issues were categorized using an existing classification system. Data collected included demographics, care pathways, levels of concern at times of health issue and survey completion, and patient-reported experiences with care. RESULTS: A total of 1289 eligible respondents completed the survey. Almost 25% (309/1289) of respondents avoided an ED presentation, of which 58% (179/309) used an alternative form of health care and 42% (130/309) self-managed. Respondents making face-to-face or telehealth appointments with their general practitioner (GP) reported high levels of ED avoidance (135/286, 47%) and mostly positive experiences of care provided by GPs. A high proportion of those who self-managed reported high levels of concern at the time of completing the survey (42/130, 32%). CONCLUSIONS: Telehealth consultations with GPs may be a more promotable alternative to the ED beyond the COVID-19 pandemic, providing easier access to a doctor with access to patients' medical histories than an appointment for a face-to-face consultation. GP telehealth consultations may also address barriers to accessing health care for those with potentially the greatest need. The reported use and positive experiences with GP telehealth appointments should inform further research on their appropriateness as an alternative to the ED.

Translating evidence-based psychological interventions for older adults with depression and anxiety into public and private mental health settings using a stepped care framework: Study protocol.

BACKGROUND: With expected increases in the number of older adults worldwide, the delivery of stepped psychological care for depression and anxiety in older populations may improve both treatment and allocative efficiency for individual patients and the health system. DESIGN: A multisite pragmatic randomised controlled trial evaluating the clinical and cost-effectiveness of a stepped care model of care for treating depression and anxiety among older adults compared to treatment as usual (TAU) will be conducted. Eligible participants (n = 666) with clinically interfering anxiety and/or depression symptoms will be recruited from and treated within six Australian mental health services. The intervention group will complete a low intensity cognitive behavioural therapy (CBT) program: Internet-delivered or using a work-at-home book with brief therapist calls (STEP 1). Following STEP 1 a higher intensity face-to-face CBT (STEP 2) will then be offered if needed. Intention-to-treat analyses will be used to examine changes in primary outcomes (e.g. clinician-rated symptom severity changes) and secondary outcomes (e.g. self-reported symptoms severity, health related quality of life and service utilisation costs). An economic evaluation will be conducted using a cost-utility analysis to derive the incremental cost-effectiveness ratio for the stepped care intervention. DISCUSSION: This study will demonstrate the relative clinical and economic benefits of stepped care model of psychological care for older adults experiencing anxiety and/or depression compared to TAU. The evaluation of the intervention within existing mental health services means that results will have significant implications for the translation of evidence-based interventions in older adult services across urban and rural settings. TRAIL REGISTRATION: Prospectively registered on anzctr.org.au (ACTRN12619000219189) and isrctn.com (ISRCTN37503850).

It's Not the Model, It's the Way You Use It: Exploratory Early Health Economics Amid Complexity Comment on "Problems and Promises of Health Technologies: The Role of Early Health Economic Modelling".

In a review recently published in this journal, Grutters et al outline the scope and impact of their early health economic modelling of healthcare innovations. Their reflections shed light on ways that health economists can shift-away from traditional reimbursement decision-support, towards a broader role of facilitating the exploration of existing care pathways, and the design of options to implement or discontinue healthcare services. This is a crucial role in organisations that face constant pressure to react and adapt with changes to their existing service configurations, but where there may exist significant disagreement and uncertainty on the extent to which change is warranted. Such dynamics are known to create complex implementation environments, where changes risk being poorly implemented or fail to be sustained. In this commentary, we extend the discussion by Grutters et al on early health economic modelling, to the evaluation of complex interventions and systems. We highlight how early health economic modelling can contribute to a participatory approach for ongoing learning and development within healthcare organisations.

Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments.

INTRODUCTION: Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts. METHODS AND ANALYSIS: This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed. ETHICS AND DISSEMINATION: Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.

Scoping review of Australian evaluations of healthcare delivery models: are we making the most of the evidence?

Objective Healthcare delivery models describe the organisation of healthcare practitioners and other resources to provide health care for a defined patient population. The organisation of health care has a predominant effect on the receipt of timely and appropriate health care. Efforts to improve healthcare delivery should be evidence informed, and large numbers of evaluations of healthcare delivery models have been undertaken. This paper presents a scoping review of Australian evaluations of new healthcare delivery models to inform a discussion of the appropriate use of such evidence to improve the efficiency and sustainability of the Australian health system. Methods A systematic scoping review was undertaken, following an a priori published protocol. PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for primary comparative studies of healthcare delivery models undertaken in Australia and published between 2009 and 2018. Primary prevention studies, such as health promotion activities, were excluded. Results Of 14923 citations, 636 studies were included in the scoping review. Of these, 383 (60%) were randomised control trials. There were 18 clinical specialties in which over 10 evaluations were identified. Most models involved allied health practitioners or nurses. Conclusion Evaluations of healthcare delivery models provide important evidence that can be used to improve the use of the most important and costly assets of health systems, namely the healthcare practitioners who deliver health care. A nationally coordinated system is required to support local health services to assess the local value of alternative healthcare delivery models. What is known about the topic? The organisation and delivery of health care is continuously evolving in response to changes in the demand and supply of health care. New healthcare delivery models are often evaluated in specific locations, but it is not clear how such evidence informs the delivery of care in other locations. What does this paper add? This paper reports the findings of a scoping review of Australian evaluations of healthcare delivery models, highlighting the large and increasing number of such evaluations that have been published in the past 10 years. What are the implications for practitioners? Opportunities to improve health system efficiency are likely being lost due to the underuse of the available Australian evidence on new healthcare delivery models. Local health services need support to interpret such evidence in their local context, which could be provided through the development of a national framework for local evaluation.

Evaluations of healthcare delivery models in Australia: a scoping review protocol.

OBJECTIVE: The aim of this review is to identify and describe the evidence base of published primary, comparative healthcare delivery model evaluations that require the employment of additional healthcare practitioners undertaken in Australia. INTRODUCTION: In Australia, formal processes are utilized in assessing the value of new pharmaceuticals and medical services, which inform decisions on whether to list new items on the Pharmaceutical Benefits Schedule and Medicare Benefits Schedule, respectively. There are no formal processes to aid in decision making on the funding of new, evaluated healthcare delivery models. This imbalance undervalues the available evidence on healthcare delivery models, leading to the sub-optimal allocation of resources between new health technologies and new healthcare delivery models within the Australian health system. INCLUSION CRITERIA: Eligible studies will evaluate healthcare delivery models that require the employment of additional healthcare practitioners (either to replace existing practitioners of another type or to provide new services). Studies must include a comparator to evaluate a condition of interest being treated using alternative healthcare delivery models, or no treatment, and will involve observation of outcomes over a similar period of time. Studies in any Australian setting will be included. Interventions aimed at primary preventions will be excluded. METHODS: PubMed, Embase and CINAHL will be searched for articles published from 2008. One reviewer will review titles, and then two reviewers will independently review abstracts to identify eligible studies. One reviewer will extract data on study characteristics and design. The results of the data extraction will be presented in a table with examples of case studies.

Screening for important unwarranted variation in clinical practice: a triple-test of processes of care, costs and patient outcomes.

Objective Unwarranted variation in clinical practice is a target for quality improvement in health care, but there is no consensus on how to identify such variation or to assess the potential value of initiatives to improve quality in these areas. This study illustrates the use of a triple test, namely the comparative analysis of processes of care, costs and outcomes, to identify and assess the burden of unwarranted variation in clinical practice. Methods Routinely collected hospital and mortality data were linked for patients presenting with symptoms suggestive of acute coronary syndromes at the emergency departments of four public hospitals in South Australia. Multiple regression models analysed variation in re-admissions and mortality at 30 days and 12 months, patient costs and multiple process indicators. Results After casemix adjustment, an outlier hospital with statistically significantly poorer outcomes and higher costs was identified. Key process indicators included admission patterns, use of invasive diagnostic procedures and length of stay. Performance varied according to patients' presenting characteristics and time of presentation. Conclusions The joint analysis of processes, outcomes and costs as alternative measures of performance inform the importance of reducing variation in clinical practice, as well as identifying specific targets for quality improvement along clinical pathways. Such analyses could be undertaken across a wide range of clinical areas to inform the potential value and prioritisation of quality improvement initiatives. What is known about the topic? Variation in clinical practice is a long-standing issue that has been analysed from many different perspectives. It is neither possible nor desirable to address all forms of variation in clinical practice: the focus should be on identifying important unwarranted variation to inform actions to reduce variation and improve quality. What does this paper add? This paper proposes the comparative analysis of processes of care, costs and outcomes for patients with similar diagnoses presenting at alternative hospitals, using linked, routinely collected data. This triple test of performance indicators extracts maximum value from routine data to identify priority areas for quality improvement to reduce important and unwarranted variations in clinical practice. What are the implications for practitioners? The proposed analyses need to be applied to other clinical areas to demonstrate the general application of the methods. The outputs can then be validated through the application of quality improvement initiatives in clinical areas with identified important and unwarranted variation. Validated frameworks for the comparative analysis of clinical practice provide an efficient approach to valuing and prioritising actions to improve health service quality.

Variation in Clinical Practice: A Priority Setting Approach to the Staged Funding of Quality Improvement.

Variation in adherence to clinical guidelines, and in the organisation and delivery of health care significantly impact patient outcomes and health service costs. Despite mounting evidence of variation in clinical practice, the funds allocated to improve the quality of existing services remain small, relative to the resources allocated to new technologies. Quality improvement is a complex intervention, with a lack of focus on outcomes, and greater uncertainty around its effects. These factors have contributed to a relatively narrow, mainstream view of quality improvement as focussing on safety, with efforts to improve adherence to best practice limited to high profile clinical areas. This paper presents an analysis of linked, routinely collected data to identify variation in patient outcomes and processes of care across hospitals for patients presenting with low-risk chest pain. Such analyses provide a low cost, broadly applicable approach to identifying potentially important areas of variation in clinical practice, to inform the prioritisation of more detailed analyses to validate, and further investigate the causes of variation.

Cost-Value Analysis and the SAVE: A Work in Progress, But an Option for Localised Decision Making?

BACKGROUND: Cost-value analysis aims to address the limitations of the quality-adjusted life-year (QALY) by incorporating the strength of public concerns for fairness in the allocation of scarce health care resources. To date, the measurement of value has focused on equity weights to reflect societal preferences for the allocation of QALY gains. Another approach is to use a non-QALY-based measure of value, such as an outcome 'equivalent to saving the life of a young person' (a SAVE). OBJECTIVE: This paper assesses the feasibility and validity of using the SAVE as a measure of value for the economic evaluation of health care technologies. METHODS: A web-based person trade-off (PTO) survey was designed and implemented to estimate equivalent SAVEs for outcome events associated with the progression and treatment of early-stage breast cancer. The estimated equivalent SAVEs were applied to the outputs of an existing decision analytic model for early breast cancer. RESULTS: The web-based PTO survey was undertaken by 1094 respondents. Validation tests showed that 68 % of eligible responses revealed consistent ordering of responses and 32 % displayed ordinal transitivity, while 37 % of respondents showing consistency and ordinal transitivity approached cardinal transitivity. Using consistent and ordinally transitive responses, the mean incremental cost per SAVE gained was £ 3.72 million. CONCLUSION: Further research is required to improve the validity of the SAVE, which may include a simpler web-based survey format or a face-to-face format to facilitate more informed responses. A validated method for estimating equivalent SAVEs is unlikely to replace the QALY as the globally preferred measure of outcome, but the SAVE may provide a useful alternative for localized decision makers with relatively small, constrained budgets-for example, in programme budgeting and marginal analysis.