Investing in acute health services: is it time to change the paradigm?

Objective: Capital is an essential enabler of contemporary public hospital services funding hospital buildings, medical equipment, information technology and communications. Capital investment is best understood within the context of the services it is designed and funded to facilitate. The aim of the present study was to explore the information on capital investment in Australian public hospitals and the relationship between investment and acute care service delivery in the context of efficient pricing for hospital services. Methods: This paper examines the investment in Australian public hospitals relative to the growth in recurrent hospital costs since 2000–01 drawing from the available data, the grey literature and the reports of six major reviews of hospital services in Australia since 2004. Results. Although the average annual capital investment over the decade from 2000–01 represents 7.1% of recurrent expenditure on hospitals, the most recent estimate of the cost of capital consumed delivering services is 9% per annum. Five of six major inquiries into health care delivery required increased capital funding to bring clinical service delivery to an acceptable standard. The sixth inquiry lamented the quality of information on capital for public hospitals. In 2012–13, capital investment was equivalent to 6.2% of recurrent expenditure, 31% lower than the cost of capital consumed in that year.Conclusions: Capital is a vital enabler of hospital service delivery and innovation, but there is a poor alignment between the available information on the capital investment in public hospitals and contemporary clinical requirements. The policy to have capital included in activity-based payments for hospital services necessitates an accurate value for capital at the diagnosis-related group (DRG) level relevant to contemporary clinical care, rather than the replacement value of the asset stock

Radiation dosimetry assessment of routine CT scanning protocols used in Western Australia

Technical data on local CT practice in Western Australia were collected for five major CT providers using a self-completed questionnaire. The CTDIvol DLP and effective dose for each protocol were obtained and providers were ranked according to radiation burden for each clinical scenario. The mean, median, 75th percentile and standard deviation were calculated for both effective dose and DLP for each scenario and these values were compared with published data. CT utilisation data were used to estimate the attributable radiation dose to the WA population and the potential change in population annual effective dose according to the protocol used was estimated. We found that wide variations in technique and radiation dose exist across providers for similar examinations, producing a higher radiation burden than reported internationally. As expected, the CT protocol used dramatically affects the radiation dose received, and this has a significant effect on annual population dose. This study highlights the need for recognition and understanding of both the degree of variation in radiation dose across providers and the relatively high radiation burden afforded by protocols in use in Western Australia so that necessary dialogue can be launched for practitioner consensus on appropriate diagnostic reference levels in CT scanning

Patient-initiated switching between private and public inpatient hospitalisation in Western Australia 1980 – 2001: An analysis using linked data

BACKGROUND: The aim of the study was to identify any distinct behavioural patterns in switching between public and privately insured payment classifications between successive episodes of inpatient care within Western Australia between 1980 and 2001 using a novel 'couplet' method of analysing longitudinal data. METHODS: The WA Data Linkage System was used to extract all hospital morbidity records from 1980 to 2001. For each individual, episodes of hospitalisation were paired into couplets, which were classified according to the sequential combination of public and privately insured episodes. Behavioural patterns were analysed using the mean intra-couplet interval and proportion of discordant couplets in each year. RESULTS: Discordant couplets were consistently associated with the longest intra-couplet intervals (ratio to the average annual mean interval being 1.35), while the shortest intra-couplet intervals were associated with public concordant couplets (0.5). Overall, privately insured patients were more likely to switch payment classification at their next admission compared with public patients (the average rate of loss across all age groups being 0.55% and 2.16% respectively). The rate of loss from the privately insured payment classification was inversely associated with time between episodes (2.49% for intervals of 0 to 13 years and 0.83% for intervals of 14 to 21 years). In all age groups, the average rate of loss from the privately insured payment classification was greater between 1981 and 1990 compared with that between 1991 and 2001 (3.45% and 3.10% per year respectively). CONCLUSION: A small but statistically significant reduction in rate of switching away from PHI over the latter period of observation indicated that health care policies encouraging uptake of PHI implemented in the 1990s by the federal government had some of their intended impact on behaviour

Development of a health care policy characterisation model based on use of private health insurance

OBJECTIVE: The aim of this study was to develop a policy characterisation process based on measuring shifts in use of private health insurance (PHI) immediately following implementation of changes in federal health care policy. METHOD: Population-based hospital morbidity data from 1980 to 2001 were used to produce trend lines in the annual proportions of public, privately insured and privately uninsured hospital separations in age-stratified subgroups. A policy characterisation model was developed using visual and statistical assessment of the trend lines associated with changes in federal health care policy. RESULTS: Of eight changes in federal health care policy, two (introduction of Medicare and Lifetime Health Cover) were directly associated with major changes in the trend lines; however, minor changes in trends were associated with several of the other federal policies. Three types of policy effects were characterised by our model: direction change, magnitude change and inhibition. Results from our model suggest that a policy of Lifetime Health Cover, with a sanction for late adoption of PHI, was immediately successful in changing the private: public mix. The desired effect of the 30% rebate was immediate only in the oldest age group (70+ years), however, introduction of the lifetime health cover and limitations in the model restricted the ability to determine whether or if the rebate had a delayed effect at younger ages. CONCLUSION: An outcome-based policy characterisation model is useful in evaluating immediate effects of changes in health care policy

Making the link: using long-term cancer survival measures linked with acute care data to plan health services.

Introduction Long-term cancer survival measures have become more important as management has improved outcomes. However, we know some cancer-related acute care use persists into the long-term. This project sought to integrate cancer survival analysis and health services research, validating our modelling retrospectively, for prospective application for health service planning. Objectives and Approach We used linked Western Australian cancer registry, mortality and hospitalisation data. Flexible parametric models for first-time invasive cancer diagnoses between 1/1/1997 and 31/12/2006 were used to extract marginal estimates of the cure proportion –that expected not to experience excess mortality from cancer - for those diagnosed in 1999. Fine and Gray competing risks regression was used to estimate the proportion who had died of non-cancer causes. The expected number of individuals diagnosed in 1999 still alive in 2011 was multiplied by the mean expected rate of cancer-related hospitalisations 12 years post-diagnosis (modelled for individuals diagnosed between 1/1/1997 and 31/12/2011). Results Cure modelling was appropriate for colorectal cancer (CRC) and melanoma. CRC cure proportions were 0.58 for ≤ 50 years at diagnosis, 0.61 for 51 – 70 years, and 0.49 for ≥71 years. For melanoma, corresponding proportions were 0.94, 0.91 and 0.83. The expected number still alive in 2011 was similar to the actual observed in the linked data for the youngest age group, with an over-estimate for older groups. The actual age-standardised, cancer-related hospitalisations in 2011 for those diagnosed with CRC or melanoma in 1999, was within the lower and upper limits of the expected number for all except melanoma diagnosed between 51 and 70 years of age. For this group, observed cancer-related hospitalisations were higher than the expected (355 versus 271 (203 – 341)). Conclusion/Implications Cancer registry linked with health service use data can provide useful insights for health service planners. While a decline in cancer-related hospitalisations from diagnosis is expected, this study shows that some demand remains 12 years post-diagnosis. Further refinement of our approach will facilitate its utility in planning cancer-related acute care

The Impact of Iterative Reconstruction on Computed Tomography Radiation Dosimetry: Evaluation in a Routine Clinical Setting

PURPOSE: To evaluate the effect of introduction of iterative reconstruction as a mandated software upgrade on radiation dosimetry in routine clinical practice over a range of computed tomography examinations. METHODS: Random samples of scanning data were extracted from a centralised Picture Archiving Communication System pertaining to 10 commonly performed computed tomography examination types undertaken at two hospitals in Western Australia, before and after the introduction of iterative reconstruction. Changes in the mean dose length product and effective dose were evaluated along with estimations of associated changes to annual cancer incidence. RESULTS: We observed statistically significant reductions in the effective radiation dose for head computed tomography (22-27%) consistent with those reported in the literature. In contrast the reductions observed for non-contrast chest (37-47%); chest pulmonary embolism study (28%), chest/abdominal/pelvic study (16%) and thoracic spine (39%) computed tomography. Statistically significant reductions in radiation dose were not identified in angiographic computed tomography. Dose reductions translated to substantial lowering of the lifetime attributable risk, especially for younger females, and estimated numbers of incident cancers. CONCLUSION: Reduction of CT dose is a priority Iterative reconstruction algorithms have the potential to significantly assist with dose reduction across a range of protocols. However, this reduction in dose is achieved via reductions in image noise. Fully realising the potential dose reduction of iterative reconstruction requires the adjustment of image factors and forgoing the noise reduction potential of the iterative algorithm. Our study has demonstrated a reduction in radiation dose for some scanning protocols, but not to the extent experimental studies had previously shown or in all protocols expected, raising questions about the extent to which iterative reconstruction achieves dose reduction in real world clinical practice

A time-duration measure of continuity of care to optimise utilisation of primary health care: A threshold effects approach among people with diabetes

© 2019 The Author(s). Background: Literature highlighted the importance of timely access and ongoing care provided at primary care settings in reducing hospitalisation and health care resource uses. However, the effect of timely access to primary care has not been fully captured in most of the current continuity of care indices. This study aimed to develop a time-duration measure of continuity of primary care ("cover index") capturing the proportion of time an individual is under the potentially protective effect of primary health care contacts. Methods: An observational study was conducted on 36,667 individuals aged 45 years or older with diabetes mellitus extracted from Western Australian linked administrative data. Threshold effect models were used to determine the maximum time interval between general practitioner (GP) visits that afforded a protective effect against avoidable hospitalisation across complication cohorts. The optimal maximum time interval was used to compute a cover index for each individual. The cover was evaluated using descriptive statistics stratified by population socio-demographic characteristics. Results: The optimal maximum time between GP visits was 9-13 months for people with diabetes with no complication, 5-11 months for people with diabetes with 1-2 complications, and 4-9 months for people with diabetes with 3+ complications. The cover index was lowest among those aged 75+ years, males, Indigenous people, socio-economically disadvantaged and those in very remote areas. Conclusions: This study developed a new measure of continuity of primary care that adds a time parameter to capturing longitudinal continuity. Cover has the potential to better capture underuse of primary care and will significantly contribute to the sparsely available methods for analysis of linked administrative data in evaluating continuity of care for people with chronic conditions

Evaluating data capture methods for the establishment of diagnostic reference levels in CT scanning

Objective: Concerns about the radiation dose associated with CT scanning have led to a call for establishment of diagnostic reference levels. Self-complete surveys have been used extensively to gather this information, however, departmental Radiological Information System's/Picture Archive Communication Systems (RIS/PACS) also hold this information. We compared dosimetry derived from survey with those using RIS/PACSs.Methods: Technical data were collected from a large metropolitan tertiary hospital in WA using both data collection methods for a range of adult CT scanning examinations. Radiation dose was calculated from both datasets and the results evaluated for several indexes of inter-rater agreement.Results: Radiation dose calculated using self-report survey data differed both systematically and proportionally from that calculated using RIS/PACS data. Differences were not consistent across CT examination type and thus not amenable to simple correction. The disparity was greater and more variable for organ dose than effective dose due to reliance of survey data on “generic” anatomical start and stop limits compared with actual data available on RIS/PACS.Conclusions: The bias observed in our study indicates that care should be taken when interpreting the results of studies measuring radiation dose using self-complete surveys. The availability of electronic databases that include information required for the evaluation and monitoring of CT radiation dose provides the opportunity to capture better quality data in a cost-effective manner. We recommend that national and local databases are established that routinely capture these data so as to facilitate the development and monitoring of radiation dose associated with CT scanning

Association between continuity of provider-adjusted regularity of general practitioner contact and unplanned diabetes-related hospitalisation: A data linkage study in New South Wales, Australia, using the 45 and Up Study cohort

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Objective To assess the association between continuity of provider-adjusted regularity of general practitioner (GP) contact and unplanned diabetes-related hospitalisation or emergency department (ED) presentation. Design Cross-sectional study. Setting Individual-level linked self-report and administrative health service data from New South Wales, Australia. Participants 27 409 survey respondents aged ≥45 years with a prior history of diabetes and at least three GP contacts between 1 July 2009 and 30 June 2015. Main outcome measures Unplanned diabetes-related hospitalisations or ED presentations, associated costs and bed days. Results Twenty-one per cent of respondents had an unplanned diabetes-related hospitalisation or ED presentation. Increasing regularity of GP contact was associated with a lower probability of hospitalisation or ED presentation (19.9% for highest quintile, 23.5% for the lowest quintile). Conditional on having an event, there was a small decrease in the number of hospitalisations or ED presentations for the low (-6%) and moderate regularity quintiles (-8%), a reduction in bed days (ranging from -30 to -44%) and a reduction in average cost of between -23% and -41%, all relative to the lowest quintile. When probability of diabetes-related hospitalisation or ED presentation was included, only the inverse association with cost remained significant (mean of A3798 to A6350 less per individual, compared with the lowest regularity quintile). Importantly, continuity of provider did not significantly modify the effect of GP regularity for any outcome. Conclusions Higher regularity of GP contact - that is more evenly dispersed, not necessarily more frequent care - has the potential to reduce secondary healthcare costs and, conditional on having an event, the time spent in hospital, irrespective of continuity of provider. These findings argue for the advocacy of regular care, as distinct from solely continuity of provider, when designing policy and financial incentives for GP-led primary care