Evaluating the cost and wait-times of a task-sharing model of care for diabetic eye care: a case study from Australia

Characteristics and Admission Preferences of Pediatric Emergency Patients and Their Waiting Time Prediction Using Electronic Medical Record Data: Retrospective Comparative Analysis

BACKGROUND

The growing number of patients visiting pediatric emergency departments could have a detrimental impact on the care provided to children who are triaged as needing urgent attention. Therefore, it has become essential to continuously monitor and analyze the admissions and waiting times of pediatric emergency patients. Despite the significant challenge posed by the shortage of pediatric medical resources in China's health care system, there have been few large-scale studies conducted to analyze visits to the pediatric emergency room.

OBJECTIVE

This study seeks to examine the characteristics and admission patterns of patients in the pediatric emergency department using electronic medical record (EMR) data. Additionally, it aims to develop and assess machine learning models for predicting waiting times for pediatric emergency department visits.

METHODS

This retrospective analysis involved patients who were admitted to the emergency department of Children's Hospital Capital Institute of Pediatrics from January 1, 2021, to December 31, 2021. Clinical data from these admissions were extracted from the electronic medical records, encompassing various variables of interest such as patient demographics, clinical diagnoses, and time stamps of clinical visits. These indicators were collected and compared. Furthermore, we developed and evaluated several computational models for predicting waiting times.

RESULTS

In total, 183,024 eligible admissions from 127,368 pediatric patients were included. During the 12-month study period, pediatric emergency department visits were most frequent among children aged less than 5 years, accounting for 71.26% (130,423/183,024) of the total visits. Additionally, there was a higher proportion of male patients (104,147/183,024, 56.90%) compared with female patients (78,877/183,024, 43.10%). Fever (50,715/183,024, 27.71%), respiratory infection (43,269/183,024, 23.64%), celialgia (9560/183,024, 5.22%), and emesis (6898/183,024, 3.77%) were the leading causes of pediatric emergency room visits. The average daily number of admissions was 501.44, and 18.76% (34,339/183,204) of pediatric emergency department visits resulted in discharge without a prescription or further tests. The median waiting time from registration to seeing a doctor was 27.53 minutes. Prolonged waiting times were observed from April to July, coinciding with an increased number of arrivals, primarily for respiratory diseases. In terms of waiting time prediction, machine learning models, specifically random forest, LightGBM, and XGBoost, outperformed regression methods. On average, these models reduced the root-mean-square error by approximately 17.73% (8.951/50.481) and increased the R2 by approximately 29.33% (0.154/0.525). The SHAP method analysis highlighted that the features "wait.green" and "department" had the most significant influence on waiting times.

CONCLUSIONS

This study offers a contemporary exploration of pediatric emergency room visits, revealing significant variations in admission rates across different periods and uncovering certain admission patterns. The machine learning models, particularly ensemble methods, delivered more dependable waiting time predictions. Patient volume awaiting consultation or treatment and the triage status emerged as crucial factors contributing to prolonged waiting times. Therefore, strategies such as patient diversion to alleviate congestion in emergency departments and optimizing triage systems to reduce average waiting times remain effective approaches to enhance the quality of pediatric health care services in China.

Implementation and scalability of shared care models for chronic eye disease: a realist assessment informed by health system stakeholders in Finland, the United Kingdom, and Australia

BACKGROUND/OBJECTIVES

Several health systems have implemented innovative models of care which share the management of patients with chronic eye diseases between ophthalmologists and optometrists. These models have demonstrated positive outcomes for health systems including increased access for patients, service efficiency and cost-savings. This study aims to understand factors which support successful implementation and scalability of these models of care.

SUBJECTS/METHODS

Semi-structured interviews were conducted with 21 key health system stakeholders (clinicians, managers, administrators, policy-makers) in Finland, United Kingdom and Australia between October 2018 and February 2020. Data were analyzed using a realist framework to identify the contexts, mechanisms of action, and outcomes of sustained and emerging shared care schemes.

RESULTS

Five key themes relating to successful implementation of shared care were identified as (1) clinician-led solutions, (2) redistributing teams, (3) building inter-disciplinary trust, (4) using evidence for buy-in, and (5) standardized care protocols. Scalability was found to be supported by (6) financial incentives, (7) integrated information systems, (8) local governance, and (9) a need for evidence of longer-term health and economic benefits.

CONCLUSIONS

The themes and program theories presented in this paper should be considered when testing and scaling shared eye care schemes to optimize benefits and promote sustainability.

The paediatric optometry alignment program - a model of interprofessional collaborative eyecare

CLINICAL RELEVANCE

Collaboration  between hospital-based ophthalmology and community-based optometry could pave the way to improve access to paediatric eyecare services.

BACKGROUND

The Paediatric Optometry Alignment Program (POAP) began in 2016 as a proof-of-concept pilot project that aimed to improve access to specialist paediatric ophthalmology services. If found to be effective at improving patient access, and the quality of care acceptable to patients and professionals then the strategic intent was to upscale the programme to  serve as a model for paediatric eye care in the community.

METHODS

Temporal observational trend analysis was used to review ophthalmology clinic appointment waitlists prior and post POAP pilot project commencement. Family satisfaction with post-discharge care was surveyed in a purposive sample of 30 patients.  Aligned optometrists in the program pilot (n = 97) were invited to complete an online survey (response rate 46%; n = 45).

RESULTS

The percentage of children waiting longer than clinically recommended fell from 72% to 36%. Sixty-seven percent  of surveyed families had attended a community optometrist as recommended, and all rated the optometry experience from good to excellent.  Participating optometrists reported high levels of satisfaction with involvement in the program, and increased confidence and involvement in paediatric eye care delivery. The need to improve formal transfer  of clinical information was identified.

CONCLUSION

Facilitated integrated care between community-based optometrists and a hospital-based ophthalmology department can improve access for tertiary care services, with high satisfaction for families and participating community-based optometrists.

The Role of Optometry in the Delivery of Eye Care via Telehealth: A Systematic Literature Review

Objective: Optometrists are increasingly adopting teleoptometry as an approach to delivering eye care. The coronavirus disease 2019 (COVID-19) pandemic has created further opportunities for optometrists to utilize innovation in telehealth to deliver eye care to individuals who experience access barriers. A systematic literature review is presented detailing the evidence to support the use of teleoptometry. Methods: Databases of MEDLINE, Global Health, and Web of Science were searched, and articles were included if they reported any involvement of optometrists in the delivery of telehealth. Findings were reported according to the mode of telehealth used to deliver eye care, telehealth collaboration type, and the format and geographical areas where eye care via telehealth is being delivered. Results: Twenty-seven relevant studies were identified. Only 11 studies included the role of optometrists as a member of the telehealth team where the scope of practice extended beyond creating and receiving referrals, collecting clinical data at in-person services, and continuing in-person care following consultation with an ophthalmologist. Both synchronous and asynchronous telehealth services were commonly utilized. Optometrists were most commonly involved in ophthalmology-led telehealth collaborations (n = 19). Eight studies reported optometrists independently delivering primary eye care via telehealth, and commonly included videoconferencing. Conclusion: The application of teleoptometry to deliver eye care is rapidly emerging, and appears to be a viable adjunct to the delivery of in-person optometry services. The review highlighted the scarcity of evidence surrounding the clinical benefits, safety, and outcomes of teleoptometry. Further research is required in this area.

Benefits of Integrating Telemedicine and Artificial Intelligence Into Outreach Eye Care: Stepwise Approach and Future Directions

Telemedicine has traditionally been applied within remote settings to overcome geographical barriers to healthcare access, providing an alternate means of connecting patients to specialist services. The coronavirus 2019 pandemic has rapidly expanded the use of telemedicine into metropolitan areas and enhanced global telemedicine capabilities. Through our experience of delivering real-time telemedicine over the past decade within a large outreach eye service, we have identified key themes for successful implementation which may be relevant to services facing common challenges. We present our journey toward establishing a comprehensive teleophthalmology model built on the principles of collaborative care, with a focus on delivering practical lessons for service design. Artificial intelligence is an emerging technology that has shown potential to further address resource limitations. We explore the applications of artificial intelligence and the need for targeted research within underserved settings in order to meet growing healthcare demands. Based on our rural telemedicine experience, we make the case that similar models may be adapted to urban settings with the aim of reducing surgical waitlists and improving efficiency.

Experiences of Patients With Diabetes Attending a Publicly Funded Eye Care Pathway in Western Sydney: A Qualitative Study

Diabetic retinopathy (DR) complications can be prevented with regular screening and timely access to an ophthalmologist for treatment. But there are patient and health system barriers that can impact access to DR services. This study aims to identify enablers and barriers for accessing public DR eye care services in a low socio-economic urban area of Australia. We conducted a qualitative study using semi-structured interviews for patients with diabetes aged 35 years and older attending public ophthalmology services. Interviews were analyzed to identify themes and subthemes; and the COM-B framework was used to interpret the complex behavioral mechanisms, including capability, opportunity, and motivation factors, to explain adherence to DR eye care. Three main themes and 7 sub-themes relating to patient experiences of DR care were derived. Patients were found to be passive actors in their DR eye care, but patients trusted clinicians and were determined to maintain their vision and quality of life. The barriers and facilitators of care related to the health system (service availability and recall–reminder systems) and patient experiences (choices, knowledge, and fear). The findings of this study will guide patient-centered initiatives to target and improve access to DR care. Strategies should focus on improving communication between eye care providers, and communication with patients to empower them to become more active players in healthcare decisions.

Review of referrals reveal the impact of referral content on the triage and management of ophthalmology wait lists

OBJECTIVES

Many chronic eye conditions are managed within public hospital ophthalmology clinics resulting in encumbered wait lists. Integrated care schemes can increase system capacity. In order to direct implementation of a public hospital-based integrated eye care model, this study aims to evaluate the quality of referrals for new patients through information content, assess triage decisions of newly referred patients and evaluate the consistency of referral content for new patients referred multiple times.

DESIGN

A retrospective and prospective review of all referral forms for new patients referred to a public hospital ophthalmology clinic between January 2016 and September 2017, and September 2017 and August 2018, respectively.

SETTING

A referral-only public hospital ophthalmology clinic in metropolitan Sydney, Australia.

PARTICIPANTS

418 new patients on existing non-urgent wait lists waiting to be allocated an initial appointment, and 528 patients who were newly referred.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the information content of referrals for new patients. The secondary outcomes were triage outcomes for new incoming referrals, and the number of new patients with multiple referrals.

RESULTS

Of the wait-listed referrals, 0.2% were complete in referral content compared with 9.8% of new incoming referrals (p<0.001). Of new incoming referrals, 56.7% were triaged to a non-urgent clinic. Multiple referrals were received for 49 patients, with no change in the amount of referral content.

CONCLUSIONS

Most referrals were incomplete in content, leading to triage based on limited clinical information. Some new patients were referred multiple times with their second referral containing a similar amount of content as their first. Lengthy wait lists could be prevented by improving administrative processes and communication between the referral centre and referrers. The future implementation of an integrated eye care model at the study setting could sustainably cut wait lists for patients with chronic eye conditions.