Measuring performance in allied health professional role substitution models of care: a clinician survey.

BACKGROUND: Professional role substitution models of care have emerged as a key strategy to address increasing healthcare demand. Gaining insights from those actively engaged in the process of these models' implementation and evaluation is pivotal to ensuring sustainability and further successful implementation. The purpose of this study was to describe allied-health clinicians' perceptions, practice, and experiences of healthcare performance evaluation in professional role substitution models of care. METHODS: Data were collected via an online platform between 22 June - 22 July 2022 using a combination of convenience and network-based sampling of allied-health clinicians involved or interested in the implementation and evaluation of professional role substitution models of care. Clinicians answered 25 questions which consisted of demographic and targeted questions regarding performance evaluation across six domains of healthcare quality (effectiveness, safety, appropriateness, access & equity, continuity of care, and cost, efficiency, productivity & sustainability). RESULTS: A total of 102 clinicians accessed the survey, with 72 providing complete survey data. Eleven allied-health professions were represented, working across twelve specialities in thirteen hospital and health services. Whilst most allied-health clinicians (93-100%) supported measuring performance in each of the six healthcare quality domains, only 26-58% were measuring these domains in practice. Allied-health leadership support (62.5%), clinician drive (62.5%), consumer engagement (50%) and medical support (46%) were enablers whilst a lack of resources (human, time, financial (47%)), healthcare performance frameworks and/or policies (40%) were identified as barriers. Given the opportunity, clinicians would invest the most financial resources in digital solutions as a core strategy to improve performance evaluation. CONCLUSIONS: Allied-health professionals expressed strong support for principles of performance evaluation, however in practice, performance evaluation is still in its infancy in professional role substitution models of care. Organisations can implement strategies that maximise the enablers whilst addressing barriers identified to improve performance evaluation in these models of care.

Patient Preferences for Attributes that Characterise Alternative Models of Care in Gastroenterology: A Discrete Choice Experiment.

OBJECTIVES: Increased demand for gastroenterology services has resulted in growing waitlists, with patients at risk of exceeding clinically recommended wait-times. Given limited healthcare resources, expanded scope models of care are an option to help address this demand, but little is known about patient preferences for these models of care. METHODS: Low-risk gastroenterology patients (n = 1198) referred to an outpatient tertiary service in Australia over a 2-year period were invited to participate in an unlabelled discrete choice experiment with seven attributes: primary healthcare professional, wait-time, continuity of care, consultation length, manner and communication skills, reassurance, and cost. These were developed using qualitative research, literature review, and stakeholders' experiences. A d-efficient fractional design was used to construct four blocks of 12 choice sets, with two alternatives. A 13th choice set was included as a data and quality check. Latent class and mixed logit regression were used for analysis. The resulting preference parameters for individual attributes were then used to calculate willingness to pay and willingness to wait. RESULTS: Overall, the model based on the 347 respondents suggested no strong preference for professional background. All other attributes were statistically significant predictors of preference (p < 0.001), with respondents willing to make significant trade-offs (time and cost) before accepting deterioration in attributes. There was strong emphasis on manner and communication skills, with a clinician who listens and provides good explanations overwhelmingly the most important attribute. Latent class analysis identified two patient segments who differed in their preference for the primary treating healthcare professional (doctor or dietitian) based on exposure to either traditional medical or non-medical professional role substitution model. CONCLUSIONS: Patients have strong but varied preferences for gastroenterology services based on whether they have been exposed to expanded scope models of care. Design and implementation of new models of care need to consider strategies to overcome any perceived loss in utility or deterioration in healthcare quality for those unfamiliar with professional role substitution.

Role substitution of specialist medical doctors with allied-health professionals: A qualitative exploration of patients' experiences and perceptions of healthcare quality.

RATIONALE, AIMS AND OBJECTIVES: The need to improve patient access, offer increased choice and improve patient outcomes whilst maintaining safe care is driving the healthcare workforce to evolve. Extending allied-health scope of practice by integrating models of care that traverse traditional professional boundaries has been one such strategy. This study explored patients' acceptance and experiences of four allied-health extended scope of practice models of care. The study aimed to identify dimensions of quality healthcare that matter to patients and describe the extent to which they perceived these to be delivered in allied-health professional role substitution models of care. METHODS: Qualitative methodology using semistructured interviews were conducted with 29 participants who had received treatment from an allied-health professional role substitution model. This was a purposeful sample with recruitment across genders, ages and social backgrounds. Interviews were audio recorded, transcribed and independently analysed by two researchers using a thematic approach. RESULTS: Six major themes were identified which revealed dimensions of healthcare quality that were important to participants: Balancing expectations and overall satisfaction; Timely access and convenience; Continuity, integration and coordination of care; Clinician expert skills, professional manner and interpersonal attributes; Financial considerations when receiving care; and Perceptions of treatment outcomes. CONCLUSIONS: This study highlights participants' views and experiences of allied-health extended scope of practice models of care. Service delivery models were an acceptable alternative to traditional specialist medical care with the perception that extended scope of practice models of care delivered many aspects of quality care that mattered to patients.

Measuring performance of professional role substitution models of care against traditional medical care in healthcare-A systematic review.

OBJECTIVES: To identify outcome measures used to evaluate performance of healthcare professional role substitution against usual medical doctor or specialist medical doctor care to facilitate our understanding of the adequacy of these measures in assessing quality of healthcare delivery. METHODS: Using a systematic approach, we searched Medline, Cochrane Central Register of Controlled Trials, Embase, CINAHL, and Web of Science from database inception until May 2020. Studies that presented original comparative data on at least one outcome measure were included following screening by two authors. Findings were synthesized, and outcome measures classified into six domains which included: effectiveness, safety, appropriateness, access, continuity of care, efficiency, and sustainability which were informed by the Institute of Medicine dimensions of healthcare quality, the Australian health performance framework, and Levesque and Sutherland's integrated performance measurement framework. RESULTS: One thirty five articles met the inclusion criteria, describing 58 separate outcome measures. Safety of role substitution models of care was assessed in 80 studies, effectiveness (n = 60), appropriateness (n = 40), access (n = 36), continuity of care (n = 6), efficiency and productivity (n = 45). Two-thirds of the studies that assessed productivity and efficiency performed an economic analysis (n = 27). The quality and rigour of evaluations varied substantially across studies, with two-thirds of all studies measuring and reporting outcomes from only one or two of these domains. CONCLUSIONS: There are a growing number of studies measuring the performance of non-medical healthcare professional substitution roles. Few have been subject to robust evaluations, and there is limited evidence on the scientific rigour and adequacy of outcomes measured. A systematic and coordinated approach is required to support healthcare settings in assessing the value of non-medical role substitution healthcare delivery models.

Health service usage and re-referral rates: comparison of a dietitian-first clinic with a medical specialist-first model of care in a cohort of gastroenterology patients.

BACKGROUND: The dietitian-first gastroenterology clinic (DFGC) is an expanded scope of practice initiative implemented in response to increased gastroenterology specialist demand. This study examined re-referral rates to gastroenterology and overall health service usage up to 24 months post management in DFGC compared with a traditional, gastroenterology specialist-first model. METHODS: Patients discharged from DFGC in the first year were matched with those seen in the traditional model. Demographic, clinical and process-related service characteristics were compared, and logistic regression analysis was undertaken to model re-presentation and model of care (MoC) as the variable of interest considering covariates in univariate analyses. Analyses were performed at 12, 18 and 24 months post discharge. RESULTS: The DFGC (122 patients) and traditional-model (62 patients) cohorts had similar baseline demographic characteristics. Wait-times (68.6 vs 272.9 days; p<0.001), treatment-times (89.4 vs 259.9 days; p<0.001) and usage of other services (1.4 vs 2.1 specialities; p=0.01) were lower in DFGC. Re-referral rates were low in both DFGC and traditional models at 12 months (0.82% vs 1.61%), 18 months (2.46% vs 6.45%) and 24 months (4.91% vs 8.06%), respectively, with no significant difference between the models at any time point. CONCLUSION: Most patients do not re-present for similar conditions within 2 years when managed in the DFGC or traditional medical model. Patients managed in DFGC have lower overall health service usage compared with patients managed in the traditional model. These findings support the safety and effectiveness of a DFGC model as one strategy to manage specialist gastroenterology service demands.

A dietitian-first gastroenterology clinic results in improved symptoms and quality of life in patients referred to a tertiary gastroenterology service.

BACKGROUND: The Dietitian First Gastroenterology Clinic (DFGC) is an initiative that has been established in response to increased gastroenterology clinical demand resulting in increased number of patients waiting outside clinically recommended timeframes for specialist care. In this clinic, a dietitian is the primary contact for eligible patients referred to tertiary gastroenterology services and provides assessment and management strategies for patients under the clinical governance of a gastroenterology consultant. This service has previously been shown to reduce patient wait-times and induce excellent patient satisfaction. Evaluation of models of care need to consider patient health outcomes as a key indicator for overall health service effectiveness. The aim of this study was to determine the impact of DFGC on patient related health outcomes. METHODS: This study utilised a pretest-posttest design of patients seen in the DFGC who met the diagnostic criteria for irritable bowel syndrome using the Rome IV criteria Consenting participants completed the validated symptom-severity (IBS-SSS) and health-related quality of life (IBSQoL) assessments. Paired sample t-tests were used to analyse differences pre- and post-management in the DFGC. Univariate mixed effects analyses were conducted to examine associations between IBS-SSS, IBSQoL and patient demographics. RESULTS: A total of 80 of 122 patients seen in the DFGC were recruited and completed baseline data, with 60 (75%) completing follow up assessments. The average participant age was 35.6 years (75% female), and IBS subtypes; IBS-C 15.0%, IBS-D 38.3%, IBS-M 26.7% and IBS-U 20.0%. Participants experienced significant reductions in symptom severity based on IBS-SSS (300.1 vs 151.7; p < 0.001) independent of IBS subtype, age or gender, with 88% (53/60) experiencing a clinically significant improvement. Quality of life significantly improved for all IBS subtypes (p < 0.001) across all subscales except food avoidance (p = 0.11). There was a moderate negative correlation between the changes in symptom severity and quality of life (R = 0.432, p = 0.001). CONCLUSIONS: Management in the DFGC provided positive patient health outcomes demonstrated by improvements in symptom severity and QoL.

Dietitian first gastroenterology clinic: an initiative to reduce wait lists and wait times for gastroenterology outpatients in a tertiary hospital service.

OBJECTIVE: The demand for outpatient gastroenterology medical specialist consultations is above what can be met within budgetary and staffing constraints. This study describes the establishment of a dietitian first gastroenterology clinic to address this issue, the patient journey and its impact on wait lists and wait times in a tertiary gastroenterology service. DESIGN: A dietitian first gastroenterology clinic model was developed and a mixed-methods approach used to evaluate the impact of the service over a 21-month period. SETTING: Gold Coast University Hospital, Queensland, Australia (a public tertiary hospital). PATIENTS: 658 patients were triaged to the clinic between June 2016 and March 2018. INTERVENTION: A dietitian first gastroenterology clinic for low-risk gastroenterology patients. MAIN OUTCOME MEASURES: We examined demographic, referral, wait list, wait time and service activity data, patient satisfaction and patient journey. RESULTS: At the time of audit, 399 new (67.9% female) and 307 review patients had been seen. Wait times for eligible patients reduced from 280 to 66 days and the percentage of those in breach of their recommended wait times reduced from 95% to zero. The average time from referral to discharge was 117.8 days with an average of 2.4 occasions of service. 277 patients (69.4%) had been discharged to the care of their general practitioner and 43 patients (10.7%) had an expedited specialist medical review. Patient surveys indicated a high level of satisfaction. CONCLUSION: A dietitian first gastroenterology model of care helps improve patient flow, reduces wait times and may be useful elsewhere to address outpatient gastroenterology service pressures.