Socio-economic composition of low-acuity paediatric presentation at a regional hospital emergency department.

"This is the pre-peer reviewed version of the following article: Alele, F. O., Callander, E. J., Emeto, T. I., Mills, J. and Watt, K. (2018), Socio‐economic composition of low‐acuity paediatric presentation at a regional hospital emergency department. J Paediatr Child Health, 54: 1341-1347. doi:10.1111/jpc.14079, which has been published in final form at http://dx.doi.org/10.1111/jpc.14079 . This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions."AIM: Despite increasing rates of emergency department (ED) utilisation, little is known about low-acuity presentations in children ≤5 years. The aims of the study were to estimate the proportion and cost of low-acuity presentations in children ≤5 years presenting to the ED and to determine the relative effect of socio-economic status (SES) on paediatric low-acuity presentations at the ED. METHODS: This is a retrospective observational study of children ≤5 years presenting to the Cairns Hospital ED over 4 years. A multivariate logistic regression model was used to assess the association between SES and low-acuity presentations. Cost of low-acuity presentations was calculated based on triage score and admission status, using costs obtained from the National Hospital Cost Data Collection. RESULTS: A total of 23 086 children were included in the study, of whom 56.7% were male (mean age = 1.85 ± 1.63 years). Approximately one-third of ED visits were low-acuity presentations (32.4%), and low-acuity presentations increased progressively with SES. In multivariate analysis, children from families with very high SES were twice as likely to have a low-acuity presentation (odds ratio 2.17; 95% confidence interval, 1.66-2.85). Low-acuity ED presentations cost the health-care system in excess of A$895 000-A$1 110 000 per year. CONCLUSIONS: These findings demonstrate that a significant proportion of paediatric ED visits are of low acuity and that these visits yield a substantial cost to the health system. Further research is required regarding care givers' rationale and potentially other reasons underlying these low-acuity ED presentations.Publishe

Tissue factor expression as a possible determinant of thromboembolism in ovarian cancer

Ovarian cancer, and clear cell carcinoma in particular, reportedly increases the risk of venous thromboembolism (VTE). However, the mechanisms remain unclear. Tissue factor (TF) supposedly represents a major factor in the procoagulant activities of cancer cells. The present study examined the involvement of TF expression in VTE for patients with ovarian cancer. Subjects comprised 32 consecutive patients (mean age 49.8 years) with histologically confirmed ovarian cancer. Presence of VTE was examined using a combination of clinical features, D-dimer levels and venous ultrasonography. Immunohistochemical analysis was used to evaluate TF expression into 4 degrees. Venous thromboembolism was identified in 10 of the 32 patients (31%), including five of the 11 patients with clear cell carcinoma. Tissue factor expression was detected in cancer tissues from 24 patients and displayed significant correlations with VTE development (P=0.0003), D-dimer concentration (P=0.003) and clear cell carcinoma (P<0.05). Multivariate analysis identified TF expression as an independent predictive factor of VTE development (P<0.05). Tissue factor (TF) expression is a possible determinant of VTE development in ovarian cancer. In particular, clear cell carcinoma may produce excessive levels of TF and is more likely to develop VTE

Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY

© 2018 The Author(s). Background: To increase the uptake of key clinical recommendations for non-surgical management of knee osteoarthritis (OA) and improve patient outcomes, we developed a new model of service delivery (PARTNER model) and an intervention to implement the model in the Australian primary care setting. We will evaluate the effectiveness and cost-effectiveness of this model compared to usual general practice care. Methods: We will conduct a mixed-methods study, including a two-arm, cluster randomised controlled trial, with quantitative, qualitative and economic evaluations. We will recruit 44 general practices and 572 patients with knee OA in urban and regional practices in Victoria and New South Wales. The interventions will target both general practitioners (GPs) and their patients at the practice level. Practices will be randomised at a 1:1 ratio. Patients will be recruited if they are aged =45 years and have experienced knee pain =4/10 on a numerical rating scale for more than three months. Outcomes are self-reported, patient-level validated measures with the primary outcomes being change in pain and function at 12 months. Secondary outcomes will be assessed at 6 and 12 months. The implementation intervention will support and provide education to intervention group GPs to deliver effective management for patients with knee OA using tailored online training and electronic medical record support. Participants with knee OA will have an initial GP visit to confirm their diagnosis and receive management according to GP intervention or control group allocation. As part of the intervention group GP management, participants with knee OA will be referred to a centralised multidisciplinary service: the PARTNER Care Support Team (CST). The CST will be trained in behaviour change support and evidence-based knee OA management. They will work with patients to develop a collaborative action plan focussed on key self-management behaviours, and communicate with the patients' GPs. Patients receiving care by intervention group GPs will receive tailored OA educational materials, a leg muscle strengthening program, and access to a weight-loss program as appropriate and agreed. GPs in the control group will receive no additional training and their patients will receive usual care. Discussion: This project aims to address a major evidence-to-practice gap in primary care management of OA by evaluating a new service delivery model implemented with an intervention targeting GP practice behaviours to improve the health of people with knee OA. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12617001595303, date of registration 1/12/2017

Current PROM and PREM use in health system performance measurement: Still a way to go

There is a growing impetus to “measure what matters” to enable health systems to optimise value-based, person-centred healthcare. This paper describes the critical importance of patient-reported outcome and experience measures (PROMs and PREMs) in this pursuit and provides an in-depth overview of how PROM and PREM programs differ between England, the United States, and Australia. A comprehensive timeline of PROM, PREM, legislation/policy, and value-based purchasing (pay-for-performance) program implementation accompanies this discussion. Importantly, this paper highlights disparities between these nations’ PROMs and PREMs programs, evidencing that we still have a way to go towards equal health system performance measurement globally

Value in maternal care: Using the Learning Health System to facilitate action.

There is an increasing need to deliver high-value health care. Here, we discuss how value should be measured and implemented in maternity care through a Learning Health System. High-value maternity care will produce the highest level of benefit for women at a given cost. As pregnancy is not an illness state, and there is no cure or remission to be achieved, we believe that patient-reported outcomes should be an integral component of benefit quantification when measuring value. Furthermore, as care impacts more than just health outcomes-particularly in maternity care-there is also a need to consider patient-reported experiences as a part of defining the level of benefit. However, to move beyond traditional narrow and passive measurement of value, we need to partner with stakeholders to identify priorities for change, identify evidence for how to achieve this change, integrate measurement activities, and promote effective implementation, in a continuous, learning cycle-a Learning Health System. A robust Framework for implementing a Learning Health System has been developed, which could be applied in maternity care

Inequities in vulnerable children's access to health services in Australia.

INTRODUCTION: Children born into families at risk of becoming or remaining poor are at significant risk of experiencing childhood poverty, which can impair their start to life, and perpetuate intergenerational cycles of poverty. This study sought to quantify health service utilisation, costs and funding distribution amongst children born into vulnerable compared to non-vulnerable families. METHODS: This study used a large linked administrative dataset for all women giving birth in Queensland, Australia between July 2012 and July 2018. Health service use included inpatient, emergency department (ED), general practice, specialist, pathology and diagnostic imaging services. Costs included those paid by public hospital funders, private health insurers, Medicare and out-of-pocket costs. RESULTS: Vulnerable children comprised 34.1% of the study cohort. Compared with non-vulnerable children, they used significantly higher average numbers of ED services during the first 5 years of life (2.52±3.63 vs 1.97±2.77), and significantly lower average numbers of specialist, pathology and diagnostic imaging services. Vulnerable children incurred significantly greater costs to public hospital funders compared with non-vulnerable children over the first 5 years of life ($16 053 vs$10 247), and significantly lower private health insurer, Medicare and out-of-pocket costs. CONCLUSION: There are clear inequities in vulnerable children's health service utilisation in Australia. Greater examination of the uptake and cost-effectiveness of maternal and child services is needed, as these services support children's development in the critical first 1000 days of life

Options for improving low birthweight and prematurity birth outcomes of indigenous and culturally and linguistically diverse infants: a systematic review of the literature using the social-ecological model.

BACKGROUND: Prematurity and low birthweight are more prevalent among Indigenous and Culturally and Linguistically Diverse infants. METHODS: To conduct a systematic review that used the social-ecological model to identify interventions for reducing low birthweight and prematurity among Indigenous or CALD infants. Scopus, PubMed, CINAHL, and Medline electronic databases were searched. Studies included those published in English between 2010 and 2021, conducted in high-income countries, and reported quantitative results from clinical trials, randomized controlled trials, case-control studies or cohort studies targeting a reduction in preterm birth or low birthweight among Indigenous or CALD infants. Studies were categorized according to the level of the social-ecological model they addressed. FINDINGS: Nine studies were identified that met the inclusion criteria. Six of these studies reported interventions targeting the organizational level of the social-ecological model. Three studies targeted the policy, community, and interpersonal levels, respectively. Seven studies presented statistically significant reductions in preterm birth or low birthweight among Indigenous or CALD infants. These interventions targeted the policy (n = 1), community (n = 1), interpersonal (n = 1) and organizational (n = 4) levels of the social-ecological model. INTERPRETATION: Few interventions across high-income countries target the improvement of low birthweight and prematurity birth outcomes among Indigenous or CALD infants. No level of the social-ecological model was found to be more effective than another for improving these outcomes

Poverty and inequality in Australia

[Extract] Bono conducted a talk for the "TED" community in 2013 about extreme poverty, health and inequality in Africa. The level of poverty amongst Australia's poor and socially disadvantaged pales in comparison. What is most concerning, however, is that poverty at all in Australia seems inconceivable because it is a developed nation, with one of the world's richest economies. Nonetheless, when applying the Australian measures of poverty, health and social disadvantage, it becomes clear that poverty is very real in some Australian populations, particularly among Aboriginal and Torres Strait Islander people. In parts of remote Australia, poverty rates reach almost 54%