Frequent avoidable admissions amongst Aboriginal and non-Aboriginal people with chronic conditions in New South Wales, Australia: a historical cohort study

Cost-effectiveness of personalised telehealth intervention for chronic disease management: A pilot randomised controlled trial

OBJECTIVE

The study aims to assess the cost-effectiveness of a personalised telehealth intervention to manage chronic disease in the long run.

METHOD

The Personalised Health Care (PHC) pilot study was a randomised trial with an economic evaluation alongside over 12 months. From a health service perspective, the primary analysis compared the costs and effectiveness of PHC telehealth monitoring with usual care. An incremental cost-effectiveness ratio was calculated based on costs and health-related quality of life. The PHC intervention was implemented in the Barwon Health region, Geelong, Australia, for patients with a diagnosis of COPD and/or diabetes who had a high likelihood of hospital readmission over 12 months.

RESULTS

When compared to usual care at 12 months, the PHC intervention cost AUD$714 extra per patient (95%CI -4879; 6308) with a significant improvement of 0.09 in health-related quality of life (95%CI: 0.05; 0.14). The probability of PHC being cost-effective by 12 months was close to 65%, at willingness to pay a threshold of AUD$50,000 per quality-adjusted life year.

CONCLUSION

Benefits of PHC to patients and the health system at 12 months translated to a gain in quality-adjusted life years with a non-significant cost difference between the intervention and control groups. Given the relatively high set-up costs of the PHC intervention, the program may need to be offered to a larger population to achieve cost-effectiveness. Long-term follow-up is required to assess the real health and economic benefits over time.

Characterising hospitalisation risk for chronic obstructive pulmonary disease exacerbations: Bedside and outpatient clinic assessments of easily measured variables

OBJECTIVE

To identify the characteristics of people with chronic obstructive pulmonary disease (COPD) who require hospitalisation for exacerbations.

METHODS

People with COPD were recruited either during hospitalisation or from out-patient respiratory medicine clinics. Hospital admissions were tracked throughout the 5-months recruitment period. For participants who were admitted, hospital readmissions were tracked for at least 30 days following discharge. Participants were grouped as either needing; (i) no hospital admission during the study period (no admission; ø-A), (ii) one or more hospital admissions during the study period but no readmission within 30 days of discharge (no rapid readmission; ø-RR) or (iii) one or more hospital admissions with a readmission within 30 days of discharge (rapid readmission; RR).

RESULTS

Compared with the ø-A group (n=211), factors that independently increased the risk of ø-RR (n=146) and/or RR (n=57) group membership were being aged >60 years, identifying as an Indigenous person (relative risk ratio, 95% confidence interval 7.8 [1.8 to 34.0]) and the use of a support person or community service for activities of daily living (1.5 [1.0 to 2.4]. A body mass index ≥25 kg/m2 was protective.

CONCLUSIONS

Variables recorded at the bedside or in clinic provided information on hospitalisation risk.

Differences in the pattern and cost of hospital care between Indigenous and non-Indigenous Australians with cirrhosis: an exploratory study

BACKGROUND

Liver diseases are important contributors to the mortality gap between Indigenous and non-Indigenous Australians.

AIMS

This cohort study examined factors associated with hospital admissions and healthcare outcomes among Indigenous Australians with cirrhosis.

METHODS

Patient-reported outcomes were obtained by face-to-face interview (Chronic Liver Disease Questionnaire and Short Form 36 (SF-36)). Clinical data were extracted from medical records and through data linkage for 534 patients (25 indigenous). Cumulative overall survival (Kaplan-Meier), rates of hospital admissions and emergency presentations, and costs were assessed by indigenous status. Incidence rate ratios (IRR; Poisson regression) were reported.

RESULTS

Indigenous Australians admitted to hospital with cirrhosis had lower educational status compared with non-indigenous patients (79.2% vs 43.4%; P < 0.001). The two groups had, in general, similar clinical characteristics including disease severity (P = 0.78), presence of cirrhosis complications (P = 0.67), comorbidities (P = 0.62), rates of cirrhosis-related admissions (P = 0.86) and 5-year survival (P = 0.30). However, indigenous patients had a lower score in the SF-36 domain related to bodily pain (P = 0.037), more cirrhosis admissions via the emergency department (IRR = 1.42, 95% confidence interval (CI) 1.10-1.83) and fewer planned cirrhosis admissions (IRR = 0.32, 95% CI 0.14-0.72). The total cost for cirrhosis-related hospital admissions for 534 patients over 6 years (July 2012 to June 2018) was A$13.7 million. The cost of cirrhosis-related hospital admissions was double for indigenous patients (cost ratio = 2.04, 95% CI 2.04-2.05).

CONCLUSIONS

Our data highlight the disparities in health service use and patient-reported outcomes, despite having similar clinical profiles. Integration between primary care, Aboriginal Community Controlled Health Organisations and liver specialists is critical for appropriate health service delivery and effective use of resources. Chronic liver disease costs the community dearly.

Comparison and outcomes of emergency department presentations with respiratory disorders among Australian indigenous and non-indigenous patients

Background

There is sparse evidence in the literature assessing emergency department presentation with respiratory disorders among Indigenous patients. The objective of this study was to evaluate the clinical characteristics and outcomes for Indigenous Australians in comparison to non-Indigenous patients presenting to Emergency Department (ED) with respiratory disorders.

Methods

In this study, two non-contiguous one-month study periods during wet (January) and dry (August) season were reported on, and differences in demographics, respiratory diagnosis, hospital admission, length of hospital stay, re-presentation to hospital after discharge and mortality between Australian Indigenous and non-Indigenous patients was assessed.

Results

There were a total of 528 respiratory ED presentations, 258 (49%) during wet and 270 (51%) in dry season, from 477 patients (52% female and 40% Indigenous). The majority of ED presentations (84%) were self-initiated, with a difference between Indigenous (80%) and non-Indigenous (88%) presentations. Indigenous presentations recorded a greater proportion of transfers from another healthcare facility compared to non-Indigenous presentations (11% vs. 1%). Less than half of presentations (42%) resulted in admission to the ward with no difference by Indigenous status. Lower respiratory tract infections were the most common cause of presentation (41%), followed by airway exacerbation (31%) which was more commonly seen among Indigenous (34%) than non-Indigenous (28%) presentations. Almost 20% of Indigenous patients reported multiple presentations to ED compared to 1% of non-Indigenous patients, though mortality on follow up did not differ (22% for both).

Conclusions

The results of this study may be an avenue to explore possibilities of implementing programs that may be helpful to reduce preventable ED presentation and recurrent hospitalisations among Indigenous population.

Implications of using the GLI-2012, GOLD and Australian COPD-X recommendations in assessing the severity of airflow limitation on spirometry among an Indigenous population with COPD: an Indigenous Australians perspective study

BACKGROUND

Assessment of airflow limitation (AFL) is crucial in the clinical evaluation of patients with chronic obstructive pulmonary disease (COPD). However, in the absence of normative reference values among adult Australian Indigenous population, the implications of utilising the Global Lung Function Initiative (GLI-2012), Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the Australian concise COPD-X recommended severity classifications is not known. Moreover, spirometry values (forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)) are observed to be 20%-30% lower in an apparently healthy Indigenous population in comparison to Caucasian counterparts.

METHODS

Adult Indigenous patients diagnosed to have COPD on spirometry (postbronchodilator (BD) FEV1/FVC <0.7 ((GOLD, (COPD-X)) and ≤lower limit of normal (others/mixed reference equations) for GLI-2012) were assessed for AFL severity classifications on Post-BD FEV1 values (mild, moderate, severe, very severe) as per the recommended classifications.

RESULTS

From a total of 742 unique patient records of Indigenous Australians, 253 were identified to have COPD via GOLD/COPD-X criteria (n=238) or GLI-2012 criteria (n=238) with significant agreeance between criteria (96%, κ=0.901). Of these, the majority were classified as having moderate or severe/very-severe AFL with significant variability across classification criteria (COPD-X (40%-43%), GOLD (33%-65%), GLI-2012 (18%-75%)). The FVC and FEV1 values also varied significantly between classification criterion (COPD-X/GOLD/GLI-2012) within the same AFL category, with COPD-X 'moderate' AFL almost matching 'severe' AFL categorisation by GOLD or GLI-2012.

CONCLUSIONS

Health professionals caring for Indigenous patients with COPD should be aware of the clinical implications and consequences of utilising various recommended AFL classifications in the absence of validated spirometry reference norms among adult Indigenous patients.