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

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

Inter-hospital transfers and door-to-balloon times for STEMI: a single centre cohort study

Background Key performance indices such as door-to-balloon times have long been recognized as quality metrics in reducing time to care for patients with acute coronary syndromes (ACS). In the situation where patients do not present to a facility capable of 24/7 percutaneous coronary interventions (PCI) delays in time to therapy can exceed the recommendation of 90 minutes or less. This study aimed to evaluate the impact of transfers on performance indices for patients diagnosed with ST-segment elevation myocardial infarction (STEMI). Methods Over a seven month collection period, all patients presenting with symptoms suggestive of ACS and admitted for PCI were studied. Patients were divided into dichotomous groups of direct presentations or transfers from a secondary non-PCI capable hospital with key times recorded, including symptom-onset, first hospital and PCI-capable hospital arrival and balloon inflation times to evaluate time of treatment for STEMI patients. Results Of the 87 patients diagnosed with STEMI, transferred patients experienced statistically significant delays in symptom-onset to the PCI-capable hospital (PCI-H) arrival (215 vs. 95 min, P < 0.001), symptom-onset to balloon inflation (225 vs. 160 min, P = 0.009) and first hospital arrival to balloon inflation times (106 vs. 56 min, P < 0.001). Only 28% (n = 9) of transferred patients underwent balloon inflation within 90 minutes from first hospital arrival, while 60% (n = 19) did within 120 minutes, although all received balloon inflation within 90 minutes from arrival at the PCI-H. After controlling for confounding factors of socio-economic status, presentation date/ time and diagnostic category, transferred patients experienced an average 162% longer delays from symptom-onset to PCI-H door arrival, and 98% longer delays in symptom-onset to balloon inflation; compared to patients who present directly to the PCI-H. No statistically significant differences were noted between transferred and direct patients when measured from PCI-H door-to-balloon times. Conclusions This study shows that transferred patients experience a greater overall system delay, compared to patients who present directly for PCI, significantly increasing their time to treatment and therefore infarct times. Despite the majority of transfers experiencing pre-hospital activation, their treatment hospital arrival to balloon times are no less than direct presenters after controlling for confounding factors, further compounding the overall delay to therapy

Hospital postdischarge intervention trialled with family caregivers of older people in Western Australia: potential translation into practice

There is lack of a suitable assessment tool that can be used routinely and systematically by hospital staff to address family caregivers' (FCs') support needs. This paper describes a novel approach to identifying and addressing FCs' needs following hospital discharge of the older person receiving care. SETTING AND PARTICIPANTS: FC recruitment occurred on the patient's discharge from a tertiary hospital in Western Australia; 64 completed the study; 80% were female; mean age 63.2 years. INTERVENTION: The Further Enabling Care at Home (FECH) programme was delivered over the telephone by a specially trained nurse and included: support to facilitate understanding of the patient's discharge letter; caregiver support needs assessment and prioritisation of urgent needs; and collaborative guidance, from the nurse, regarding accessing supports. RESULTS: Sixty-four FCs completed the FECH programme. The top three support needs identified by the FCs were: knowing what to expect in the future (52%), knowing who to contact if they were concerned (52%) and practical help in the home (36%). The telephone-based outreach service worked well and was convenient for the nurse and the FCs, and saved on transport, time and money. Most of the FCs appreciated the systematic approach to identify and articulate their needs and were satisfied with the support they received, mainly navigation through the systems, problem solving, self-care strategies, explanation of illness, symptoms and medication and access to after-hours services. CONCLUSIONS: In order to guide services which may consider adopting this systematic approach to supporting FCs and integrating it into their routine practice, this evaluation of the FECH programme has described the processes implemented and highlighted the factors that hindered or facilitated these processes to engage caregivers with appropriate services in a timely manner. Positive feedback indicated that the programme was a useful addition to hospital discharge planning. TRIAL REGISTRATION NUMBER: ACTRN12614001174673; Results

Challenging the perceptions of cancer service provision for the disadvantaged: evaluating utilisation of cancer support services in Western Australia

Purpose: The main aim of the study was to evaluate the distributive utilisation of services provided by the Cancer Council of Western Australia according to age, social disadvantage and geographic location. Results were used to determine if social justice principles in terms of service provision were upheld. Methods: Cross-sectional study design to evaluate utilisation of cancer support services over a 12-week period in 2007 using administrative records. Service utilisation incidence rates (population information obtained from de-identified cancer registry data) and incidence rate ratios were calculated by gender, age group, cancer type, socioeconomic status and location. Results: The Information services (52%, n = 4,932) were the most popular Cancer Council of Western Australia (CCWA) services followed by Emotional Support services (21%, n =  2,045). All CCWA services were more likely to be accessed by those with a lower socioeconomic status, except for Clinical Services. The rate of utilisation for patients with cancer in the 65+ years age group was found to be under-serviced relative to the 40–64 years age group. Conclusions: Overall, the study has shown that CCWA services are not provided uniformly (horizontal equity) across strata of socio-economic status. Given that the prevalence of cancer generally increases with socio-economic advantage, the findings were notable in regard to one particular outcome. Results for age indicate that there may be some underlying accessibility issues for the aged population. The findings are consistent with current literature highlighting issues of disadvantage in regard to the ability of elderly persons with cancer to access services and support

Demonstration of the Effect of Generic Anatomical Divisions versus Clinical Protocols on Computed Tomography Dose Estimates and Risk Burden

Objective: Choosing to undertake a CT scan relies on balancing risk versus benefit, however risks associated with CT scanning have generally been limited to broad anatomical locations, which do not provided adequate information to evaluate risk against benefit. Our study aimed to determine differences in radiation dose and risk estimates associated with modern CT scanning examinations when computed for clinical protocols compared with those using anatomical area. Methods: Technical data were extracted from a tertiary hospital Picture Archiving Communication System for random samples of 20–40 CT examinations per adult clinical CT protocol. Organ and whole body radiation dose were calculated using ImPACT Monte Carlo simulation software and cancer incidence and mortality estimated using BEIR VII age and gender specific lifetime attributable risk weights. Results: Thirty four unique CT protocols were identified by our study. When grouped according to anatomic area the radiation dose varied substantially, particularly for abdominal protocols. The total estimated number of incident cancers and cancer related deaths using the mean dose of anatomical area were 86 and 69 respectively. Using more specific protocol doses the estimates rose to 214 and 138 incident cancers and cancer related deaths, at least doubling the burden estimated. Conclusions: Modern CT scanning produces a greater diversity of effective doses than much of the literature describes; where a lack of focus on actual scanning protocols has produced estimates that do not reflect the range and complexity of modern CT practice. To allow clinicians, patients and policy makers to make informed risk versus benefit decisions the individual and population level risks associated with modern CT practices are essential

Supportive care of patients diagnosed with high grade glioma and their carers in Australia.

PURPOSE: This study aimed to: determine the supportive care available for Australian patients with High Grade Glioma (HGG) and their carers; identify service gaps; and inform changes needed to implement guidelines and Optimal Care Pathways. METHODS: This cross-sectional online survey recruited multidisciplinary health professionals (HPs) who were members of the Cooperative Trials Group for Neuro-Oncology involved in management of patients diagnosed with HGG in Australian hospitals. Descriptive statistics were calculated. Fisher's exact test was used to explore differences between groups. RESULTS: 42 complete responses were received. A majority of MDT meetings were attended by a: neurosurgeon, radiation oncologist, medical oncologist, radiologist, and care coordinator. Less than 10% reported attendance by a palliative care nurse; physiotherapist; neuropsychologist; or speech therapist. Most could access referral pathways to a cancer care coordinator (76%), neuropsychologist (78%), radiation oncology nurse (77%), or psycho-oncologist (73%), palliative care (93-100%) and mental health professionals (60-85%). However, few routinely referred to an exercise physiologist (10%), rehabilitation physician (22%), dietitian (22%) or speech therapist (28%). Similarly, routine referrals to specialist mental health services were not standard practice. Nearly all HPs (94%) reported HGG patients were advised to present to their GP for pre-existing conditions/comorbidities; however, most HPs took responsibility (≤ 36% referred to GP) for social issues, mental health, symptoms, cancer complications, and treatment side-effects. CONCLUSIONS: While certain services are accessible to HGG patients nationally, improvements are needed. Psychosocial support, specialist allied health, and primary care providers are not yet routinely integrated into the care of HGG patients and their carers despite these services being considered essential in clinical practice guidelines and optimal care pathways

Balance on the Brain: a randomised controlled trial evaluating the effect of a multimodal exercise programme on physical performance, falls, quality of life and cognition for people with mild cognitive impairment—study protocol

Introduction: Exercise and physical activity have been shown to improve cognition for people living with mild cognitive impairment (MCI). There is strong evidence for the benefits of aerobic exercise and medium evidence for participating in regular strength training for people with MCI. However, people living with MCI fall two times as often as those without cognitive impairment and the evidence is currently unknown as to whether balance training for people with MCI is beneficial, as has been demonstrated for older people without cognitive impairment. The aim of this study is to determine whether a balance-focused multimodal exercise intervention improves balance and reduces falls for people with MCI, compared with a control group receiving usual care. Methods and analysis: This single blind randomised controlled trial (Balance on the Brain) will be offered to 396 people with MCI living in the community. The multimodal exercise intervention consists of two balance programmes and a walking programme to be delivered by physiotherapists over a 6-month intervention period. All participants will be followed up over 12 months (for the intervention group, this involves 6-month intervention and 6-month maintenance). The primary outcomes are (1) balance performance and (2) rate of falls. Physical performance, levels of physical activity and sedentary behaviour, quality of life and cognition are secondary outcomes. A health economic analysis will be undertaken to evaluate the cost-effectiveness of the intervention compared with usual care. Ethics and dissemination: Ethics approval has been received from the South Metropolitan Health Service Human Research Ethics Committee (HREC), Curtin University HREC and the Western Australia Department of Health HREC; and approval has been received to obtain data for health costings from Services Australia. The results will be disseminated through peer-review publications, conference presentations and online platforms

Trend in CT utilisation and its impact on length of stay, readmission and hospital mortality in Western Australia tertiary hospitals: an analysis of linked administrative data 2003-2015

Objective: High use of CT scanning has raised concern due to the potential ionising radiation exposure. This study examined trends of CT during admission to tertiary hospitals and its associations with length of stay (LOS), readmission and mortality. Design Retrospective observational study from 2003 to 2015. Setting: West Australian linked administrative records at individual level. Participants: 2 375 787 episodes of tertiary hospital admission in adults aged 18+ years. Main outcome measures: LOS, 30-day readmissions and mortality stratified by CT use status (any, multiple (CTs to multiple areas during episode), and repeat (repeated CT to the same area)). Methods: Multivariable regression models were used to calculate adjusted rate of CT use status. The significance of changes since 2003 in the outcomes (LOS, 30-day readmission and mortality) was compared among patients with specific CT imaging status relative to those without. Results: Between 2003 and 2015, while the rate of CT increased 3.4% annually, the rate of repeat CTs significantly decreased −1.8% annually and multiple CT showed no change. Compared with 2003 while LOS had a greater decrease in those with any CT, 30- day readmissions had a greater increase among those with any CT, while the probability of mortality remained unchanged between the any CT/no CT groups. A similar result was observed in patients with multiple and repeat CT scanning, except for a significant increase in mortality in the recent years in the repeat CT group. Conclusion: The observed pattern of increase in CT utilisation is likely to be activity-based funding policydriven based on the discordance between LOS and readmissions. Meanwhile, the repeat CT reduction aligns with a more selective strategy of use based on clinical severity. Future research should incorporate in-hospital and out-of-hospital CT to better understand overall CT trends and potential shifts between settings over time.Thi Ninh Ha, Sviatlana Kamarova, David Youens, Cameron Wright, Donald McRobbie, Jenny Doust, John Slavotinek, Max K Bulsara, Rachael Moori

Cohort study of Western Australia computed tomography utilisation patterns and their policy implications

Background: Computed tomography (CT) scanning is a relatively high radiation dose diagnostic imaging modality with increasing concerns about radiation exposure burden at the population level in scientific literature. This study examined the epidemiology of adult CT utilisation in Western Australia (WA) in both the public hospital and private practice settings, and the policy implications. Methods: Retrospective cohort design using aggregate adult CT data from WA public hospitals and Medical Benefits Schedule (MBS) (mid-2006 to mid-2012). CT scanning trends by sex, age, provider setting and anatomical areas were explored using crude CT scanning rates, age-standardised CT scanning rates and Poisson regression modelling. Results: From mid-2006 to mid-2012 the WA adult CT scanning rate was 129 scans per 1,000 person-years (PY). Females were consistently scanned at a higher rate than males. Patients over 65 years presented the highest scanning rates (over 300 scans per 1,000 PY). Private practice accounted for 73% of adult CT scans, comprising the majority in every anatomical area. In the private setting females predominately held higher age-standardised CT scanning rates than males. This trend reversed in the public hospital setting. Patients over 85 years in the public hospital setting were the most likely age group CT scanned in nine of ten anatomical areas. Patients in the private practice setting aged 85+ years were relatively less prominent across every anatomical area, and the least likely age group scanned in facial bones and multiple areas CT scans.Conclusion: In comparison to the public hospital setting, the MBS subsidised private sector tended to service females and relatively younger patients with a more diverse range of anatomical areas, constituting the majority of CT scans performed in WA. Patient risk and subsequent burden is greater for females, lower ages and some anatomical areas. In the context of a national health system, Australia has various avenues to monitor radiation exposure levels, improve physician training and modify funding mechanisms to ensure individual and population medical radiation exposure is as low as reasonably achievable