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

Does A Dietitian-Led Celiac Disease Clinic (DLCC) Facilitate Timely Diagnosis and Nutrition Care for Patients With Celiac Disease?

BACKGROUND AND AIM

Given lengthy diagnosis and treatment delays existed for adult outpatients with newly diagnosed celiac disease (CD), a dietitian-led celiac disease clinic (DLCC) was implemented in 2020. Under DLCC, the dietitian removed eligible patients from the gastroenterology waitlist and ordered pathology and endoscopy for CD diagnosis, and those with CD were given timely, regular dietetic education. This pretest/posttest study aimed to compare time to CD diagnosis and treatment, and the proportion of patients were offered gastroenterologist appointments between the previous (pre-DLCC) and the DLCC expanded scope (post-DLCC) clinics.

METHODS

Eligible patients were adults, referred to the gastroenterology dietitian between 2018 and 2021, with newly diagnosed CD. Demographic, medical, and appointment data were sourced from medical records. A satisfaction survey was administered to post-DLCC patients. Chi-squared and t-tests were used to compare groups.

RESULTS

Fifty-four patients were eligible (69%F, 43 ± 15 years, 86% had anti-TTG > 20 U/mL, n = 33 post-DLCC). Time from gastroenterologist referral triage to treatment commencement was improved by 404 days from pre- to post-DLCC (p < 0.01) in those whose CD diagnosis was not led by nursing staff, with reductions observed in both time from referral triage to CD diagnosis and CD diagnosis to treatment (p < 0.05). These improvements were conservative given COVID-19 delayed services for most (n = 29/33) post-DLCC patients. Thirty-six percent fewer post-DLCC patients were offered gastroenterologist appointments (p < 0.01). All (100%) post-DLCC respondents reported satisfaction with the clinic.

CONCLUSION

A DLCC expanded scope clinic may provide more timely diagnosis and treatment access for adult patients with newly diagnosed CD, with fewer requiring gastroenterologist appointments.

The Evolving Landscape of Discrete Choice Experiments in Health Economics: A Systematic Review

INTRODUCTION

Stakeholder preference evaluations are increasingly emphasized in healthcare policy and health technology assessment. Discrete choice experiments (DCEs) are the most common method for quantifying preferences among patients, the public, and healthcare professionals. While prior reviews (1990-2017) have examined DCE trends, no comprehensive synthesis exists for studies published since 2018. This updated review (2018-2023) provides critical insights into evolving methodologies and global trends in health-related DCEs.

METHODS

A systematic search (2018-2023) of Medline, Embase, and Web of Science identified relevant studies. Studies were screened for inclusion and data were extracted, including details on DCE design and analysis. To enable trend comparisons, the search strategy and extraction items aligned with previous reviews.

RESULTS

Of 2663 identified papers, 1279 met the inclusion criteria, reflecting a significant rise in published DCEs over time. DCEs were conducted globally, with a remarkable increase in publications from Asia and Africa compared with previous reviews. Experimental designs and econometric models have advanced, continuing prior trends. Notably, most recent DCEs were administered online.

DISCUSSION

The rapid growth of DCE applications underscores their importance in health research. While the methodology is advancing rapidly, it is crucial that researchers provide full transparency in reporting their methods, particularly in detailing experimental designs and validity tests, which are too often overlooked. Key recommendations include improving reporting of experimental designs, applying validity tests, following good practices for presenting benefit-risk attributes, and adopting open science practices. Ensuring methodological rigor will maximize the impact and reproducibility of DCE research in health economics.

Using Best-Worst Scaling Survey to Investigate the Relative Importance of Attributes Associated with Public Hospital Outpatient Appointments

INTRODUCTION

Obtaining patient input before healthcare redesign improves patient experience. The Townsville Hospital and Health Service, a regional Australian public health service, seeks to reduce the long wait list for medical specialist appointments by introducing allied health substitution models of care for low-acuity patients. This paper describes a best worst scaling survey conducted to refine attributes associated with outpatient appointments which will be used in a future discrete choice experiment (DCE).

METHODS

A literature review was conducted to identify attributes associated with medical specialist outpatient appointments and allied health substitution models. An object (or case 1) best worst scaling (BWS) survey was designed using blocks of a balanced incomplete block design and analysed using multinomial logit and mixed logit models. Patients waiting at local specialist outpatient clinics were invited to complete the survey via an iPad. The interviewer collected field notes, which were analysed using content analysis.

RESULTS

A total of 12 attributes were identified in the literature review and one from local discussion. The 167 completed responses demonstrated the ranking of attributes were diagnostic accuracy, symptom relief, continuity of care, satisfaction with care, healthcare professional, manner and communication, time on waitlist and onward referral. The least important attributes were reassurance offered, appointment wait time, cost and appointment duration.

CONCLUSIONS

This BWS survey allows us to reduce the attributes for inclusion in the DCE from 13 to 8. Diagnostic accuracy and symptom relief were of most importance, and appointment wait time and duration were of least importance. This suggests that patients would be willing to be attend different models of care such as allied health primary contact model if clinical outcomes were equivalent to the current medical-led models.

Performance Understanding and Learning System (PULSE-KEY): development of a framework for implementation and performance evaluation of healthcare delivery models of care

OBJECTIVES

Efficient performance evaluation is essential for driving improvement, ensuring accountability and optimisation of outcomes in healthcare delivery. However, its complexity often leads to ineffective implementation. This article aims to advance the field of performance measurement within alternative healthcare delivery models of care through the development and validation of a comprehensive evaluation framework.

DESIGN AND PARTICIPANTS

A seven-stage methodological approach was adapted from the Health Care Quality Indicators Project and a conceptual analysis method. The first three stages, which have been previously published, included: (1) an extensive literature review, (2) engagement with consumers and patients through interviews and a discrete choice experiment and (3) involvement of stakeholders across the healthcare system via interviews and surveys. Building on this previous work, the present study advances the framework development through four additional stages: (4) development of a conceptual framework (identifying, categorising, synthesising concepts into outcome domains), (5) expert consultation, (6) validation using a real-world case study and (7) refinement for practical applicability and effectiveness in evaluating alternative healthcare delivery models of care.

RESULTS

The framework was developed by synthesising insights from phases 1-3 of our previously published work and refined through consultations with 25 experts, confirming its relevance, clarity and suitability for diverse audiences. This study also details the framework's validation, refinement and finalisation process. The final framework is structured around eight primary domains, covering implementation outcomes, effectiveness, safety, patient-centredness, healthcare provider experience, access, service delivery and economic evaluation. Within the implementation outcomes domain, three subdomains-adoptability, implementability and sustainability-are further delineated, providing a comprehensive assessment.

CONCLUSIONS

The comprehensive evaluation framework developed in this study provides a vital tool for enhancing implementation and performance measurement in alternative healthcare delivery models. By integrating insights from various stakeholders, the framework promotes data-driven decisions on adopting, implementing and sustaining various healthcare delivery models. Through systematic application, this framework aims to drive tangible enhancements in patient outcomes, improve healthcare provider experiences, and optimise overall healthcare system efficiency.

Evaluating allied health primary contact models of care: A mixed methods analysis of current practice

RATIONALE

Allied Health Primary Contact Clinic (AHPCC) models of care are increasingly used to manage growing demands on health service capacity. There is a critical need for new models of care to demonstrate value, however comprehensive evaluation of AHPCCs, including use of metrics frameworks like the Moretto framework, have been slow to uptake, and the reasons for this are unclear.

AIMS AND OBJECTIVES

To understand current evaluation practices as mapped to the Moretto framework, and explore clinician attitudes to the process of service evaluation across a variety of AHPCC models implemented within a metropolitan health service in Queensland, Australia.

METHOD

A convergent mixed methods approach was used. Data were collected in 2022 using a quantitative presurvey, followed by a qualitative descriptive interview with AHPCC lead clinicians. Thirty AHPCCs were eligible, and all potential participants who provided consent were included. Descriptive statistics and thematic analysis were used for quantitative and qualitative data respectively, then merged and reported jointly.

RESULTS

Twenty-three clinicians representing 22 different AHPCCs participated. AHPCC models were found to be complex and varied. Evaluation practices were variable across AHPCCs, although more than half collected most of the Moretto framework measures. Quality of life and resource use measures were least commonly collected. Themes regarding participants' experience of AHPCCs evaluation were that: Evaluation is complex and challenging; Evaluation is important; and Evaluation needs to be enabled.

CONCLUSION

For health services to fully understand the value of their AHPCC services and direct their limited resources appropriately, evaluation activity needs to be better valued and enabled at a local, statewide and national level. Strategies should include protected time, funding, administrative support, leadership support, access to mentorship, development of structures which enable collaborative evaluation at a state-wide (or broader) level, and a shared understanding of value and core areas for measurement across stakeholders.

Unlocking potential: a qualitative exploration guiding the implementation and evaluation of professional role substitution models in healthcare

BACKGROUND

As role substitution models gain prominence in healthcare, understanding the factors shaping their effectiveness is paramount. This study aimed to investigate factors that impact the implementation and performance evaluation of professional role substitution models in healthcare, with a focus on understanding the variables that determine their success or failure in adoption, execution, continuity, and outcomes.

METHODS

The exploratory qualitative study used semi-structured interviews with key opinion leaders, decision makers, facilitators, recipients, and frontline implementers, who had influence and involvement in the implementation of professional role substitution models. Data analysis was guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Between November 2022 and April 2023, 39 stakeholders were interviewed. Factors influencing implementation and evaluation of allied health professional role substitution models of care aligned with the five core CFIR domains (innovation, outer setting, inner setting, individuals, implementation process) and outcome domain incorporating implementation and innovation outcomes. The six themes identified within these CFIR domains were, respectively; i) Examining the dynamics of innovation catalysts, evidence, advantages, and disadvantages; ii) Navigating the complex landscape of external factors that influence implementation and evaluation; iii) Impact of internal structural, political, and cultural contexts; iv) The roles and contributions of individuals in the process; v) Essential phases and strategies for effective implementation; and vi) The assessment of outcomes derived from allied health professional role substitution models.

CONCLUSIONS

The study highlights the complex interplay of contextual and individual factors that influence the implementation and performance evaluation of professional role substitution models. It emphasises the need for collaboration among diverse stakeholders to navigate the challenges and leverage the opportunities presented by expanded healthcare roles. Understanding these multifaceted factors can contribute to the development of an empowered workforce and a healthcare system that is more efficient, effective, safe, and sustainable, ultimately benefiting patients.

'The big value of it is getting the patient seen by the right person at the right time': clinician perceptions of the value of allied health primary contact models of care

Allied health primary contact clinic models of care have increasingly been used as a strategy to increase public health service capacity. A recent systematic review found little consistency or agreement on how primary contact clinics are evaluated. The concept of value of primary contact clinics, which has important implications for evaluation, has not yet been explored in-depth. To explore allied health clinicians' perceptions of the value of allied health primary contact clinics, with the goal of informing an evaluation framework, a descriptive qualitative approach utilizing semi-structured interviews was employed. Participants included allied health staff embedded in clinical lead roles within primary contact clinics across four acute care hospitals in a metropolitan health service located in South-East Queensland, Australia. Lead staff from 30 identified primary contact clinic models in the health service were approached to take part via email. All eligible participants who provided consent were included. An inductive thematic analysis approach was used. A total of 23 clinicians (n = 23) representing 22 diverse models of primary contact clinics participated. Most participants were physiotherapists, dietitians, or occupational therapists, although speech pathology, audiology, and podiatry were also represented. Participant perceptions of the 'value' of PCCs were a highly complex phenomenon, comprising five intersecting domains: (i) patient satisfaction; (ii) clinical outcomes; (iii) care pathway and resource use; (iv) health service performance; and (v) staff satisfaction and professional standing. These five core value domains were positively or negatively influenced by 12 perceived benefits and 8 perceived drawbacks, respectively. Value domains were also highly interrelated and impacted upon each other. The concept of 'value' relating to primary contact clinics involves multiple intersecting domains encompassing different perspectives. This study highlighted potential benefits and drawbacks of primary contact clinics that have not yet been measured or explored in the literature, and as such may be useful for healthcare administrators to consider. The findings of this study will inform an evaluation framework including health economics calculator for primary contact clinics.

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.