Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial

BACKGROUND: Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional &quot;waitlist and triage&quot; model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction. METHODS/DESIGN: A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12&nbsp;weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial. DISCUSSION: This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care.<br /

A model of access combining triage with initial management reduced waiting time for community outpatient services: a stepped wedge cluster randomised controlled trial

BACKGROUND: Long waiting times are associated with public community outpatient health services. This trial aimed to determine if a new model of care based on evidence-based strategies that improved patient flow in two small pilot trials could be used to reduce waiting time across a variety of services. The key principle of the Specific Timely Appointments for Triage (STAT) model is that patients are booked directly into protected assessment appointments and triage is combined with initial management as an alternative to a waiting list and triage system. METHODS: A stepped wedge cluster randomised controlled trial was conducted between October 2015 and March 2017, involving 3116 patients at eight sites across a major Australian metropolitan health network. RESULTS: The intervention reduced waiting time to first appointment by 33.8% (IRR&thinsp;=&thinsp;0.663, 95% CI 0.516 to 0.852, P&thinsp;=&thinsp;0.001). Median waiting time decreased from a median of 42&nbsp;days (IQR 19 to 86) in the control period to a median of 24&nbsp;days (IQR 13 to 48) in the intervention period. A substantial reduction in variability was also noted. The model did not impact on most secondary outcomes, including time to second appointment, likelihood of discharge by 12&nbsp;weeks and number of appointments provided, but was associated with a small increase in the rate of missed appointments. CONCLUSIONS: Broad-scale implementation of a model of access and triage that combined triage with initial management and actively managed the relationship between supply and demand achieved substantial reductions in waiting time without adversely impacting on other aspects of care. The reductions in waiting time are likely to have been driven, primarily, by substantial reductions for those patients previously considered low priority. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615001016527 registration date: 29/09/2015

The harlequin ladybird, Harmonia axyridis: global perspectives on invasion history and ecology

The harlequin ladybird, Harmonia axyridis (Pallas) (Coleoptera: Coccinellidae), is native to Asia but has been intentionally introduced to many countries as a biological control agent of pest insects. In numerous countries, however, it has been introduced unintentionally. The dramatic spread of H. axyridis within many countries has been met with considerable trepidation. It is a generalist top predator, able to thrive in many habitats and across wide climatic conditions. It poses a threat to biodiversity, particularly aphidophagous insects, through competition and predation, and in many countries adverse effects have been reported on other species, particularly coccinellids. However, the patterns are not consistent around the world and seem to be affected by many factors including landscape and climate. Research on H. axyridis has provided detailed insights into invasion biology from broad patterns and processes to approaches in surveillance and monitoring. An impressive number of studies on this alien species have provided mechanistic evidence alongside models explaining large-scale patterns and processes. The involvement of citizens in monitoring this species in a number of countries around the world is inspiring and has provided data on scales that would be otherwise unachievable. Harmonia axyridis has successfully been used as a model invasive alien species and has been the inspiration for global collaborations at various scales. There is considerable scope to expand the research and associated collaborations, particularly to increase the breadth of parallel studies conducted in the native and invaded regions. Indeed a qualitative comparison of biological traits across the native and invaded range suggests that there are differences which ultimately could influence the population dynamics of this invader. Here we provide an overview of the invasion history and ecology of H. axyridis globally with consideration of future research perspectives. We reflect broadly on the contributions of such research to our understanding of invasion biology while also informing policy and people

Pseudomonas aeruginosa in children with cerebral palsy : a prospective study

Abstract: Introduction: Children with cerebral palsy (CP) often present with chronic respiratory symptoms. Pseudomonas aeruginosa (PA), is a known pathogen associated with more severe respiratory disease. Preventive actions to eradicate this bacterium and to improve the respiratory condition of children with CP could be very valuable. Therefore, we assessed the prevalence of PA and its association with respiratory disease.Methods: Throat swabs were taken in children with CP, aged 0-18 years. Data from patient records were extracted from the electronic medical records. Follow-up of respiratory symptoms was done by the Liverpool respiratory symptom questionnaire (LRSQ) after 3 months.Results: A throat swab and a completed LRSQ after 3 months were received from 79 children with CP. Twenty-eight patients (35.4%) were found to have at least one positive respiratory culture. Only 4 patients (5.1%) were contaminated with PA. Gram negative bacteria were isolated in 21.5% of the positive throat swabs, S. aureus was found in 13.9%. Most pathogens were found in patients with higher GMFCS score (GMFCS IV and V). Results of the LRSQ showed that 52.1% of these patients reported having 1 cold in the past 3 months.Discussion: The prevalence of PA in our population of children with CP is low, gram-negative bacteria were most commonly found. The respiratory consequences of being colonized with these bacteria were limited. These results may have been affected by the COVID-19 pandemic. Further research is recommended

Pseudomonas aeruginosa in children with cerebral palsy: a prospective study

IntroductionChildren with cerebral palsy (CP) often present with chronic respiratory symptoms. Pseudomonas aeruginosa (PA), is a known pathogen associated with more severe respiratory disease. Preventive actions to eradicate this bacterium and to improve the respiratory condition of children with CP could be very valuable. Therefore, we assessed the prevalence of PA and its association with respiratory disease.MethodsThroat swabs were taken in children with CP, aged 0–18 years. Data from patient records were extracted from the electronic medical records. Follow-up of respiratory symptoms was done by the Liverpool respiratory symptom questionnaire (LRSQ) after 3 months.ResultsA throat swab and a completed LRSQ after 3 months were received from 79 children with CP. Twenty-eight patients (35.4%) were found to have at least one positive respiratory culture. Only 4 patients (5.1%) were contaminated with PA. Gram negative bacteria were isolated in 21.5% of the positive throat swabs, S. aureus was found in 13.9%. Most pathogens were found in patients with higher GMFCS score (GMFCS IV and V). Results of the LRSQ showed that 52.1% of these patients reported having 1 cold in the past 3 months.DiscussionThe prevalence of PA in our population of children with CP is low, gram-negative bacteria were most commonly found. The respiratory consequences of being colonized with these bacteria were limited. These results may have been affected by the COVID-19 pandemic. Further research is recommended