Allied health primary contact services: results of a 2-year follow-up study of clinical effectiveness, safety, wait times and impact on medical specialist out-patient waitlists

Objective Long specialist out-patient waitlists are common in public health facilities, but not all patients require consultation with a medical specialist. Studies of single allied health primary contact services have shown they provide timely, appropriate care and reduce demand on medical specialist out-patient waitlists. This study evaluated the collective benefits across multiple allied health primary contact services and models to determine their clinical effectiveness, safety, timeliness of care and impact on medical specialist out-patient waitlists. Method Using a prospective observational study design, data were collected and analysed for patients attending 47 allied health primary contact services in Queensland public hospitals over a 2-year period. Outcomes reported are global status, adverse events, wait times and impact on medical specialist out-patient waitlists. Results In all, 10634 patients were managed in and discharged from the allied health services. Most adult patients (80%) who attended at least two consultations reported an improvement in health status. No adverse events were attributed to the model of care. Approximately 68%, 44% and 90% of urgent, semi-urgent and non-urgent out-patients respectively were seen within clinically recommended time frames. Between 35% and 89% of patients were removed from out-patient waitlists without medical specialist consultation across the service models. Conclusions Allied health primary contact services provide safe, effective and timely care. The impact on medical specialist out-patient waitlists varied depending on service model and pathway characteristics. What is known about this topic? Most studies of allied health primary contact services have focused on the management of patients on orthopaedic specialist out-patient waitlists by a physiotherapist. These studies of either individual services or groups of services with the same model cite benefits, including reduced waiting times, high levels of patient and referrer satisfaction, improved conversion to surgery, cost-effectiveness and more effective utilisation of medical specialists. What does this paper add? This paper highlights that, collectively, allied health primary contact services are safe, effective and provide timely care. The proportion of patients independently managed and removed from various medical specialist out-patient waitlists and the services involved are reported, demonstrating the variety of service models. This study reports outcomes for primary contact services for which there is a dearth of published literature, including dietician services for patients on gastroenterology waitlists, speech pathology and audiology services for patients on ear, nose and throat waitlists, occupational therapy hand services for patients on orthopaedic waitlists and physiotherapy led pelvic-health services for patients on gynaecology waitlists. Possibilities for efficiency gains are identified and discussed. What are the implications for practitioners? Health service managers should consider allied health primary contact services as a viable option to increase specialist out-patient capacity. Service model characteristics that maximise impact on medical specialist out-patient waitlist management are highlighted to inform resource allocation.

Translating research into practice: outcomes from the Healthy Living after Cancer partnership project

BACKGROUND

Healthy Living after Cancer (HLaC) was a national dissemination and implementation study of an evidence-based lifestyle intervention for cancer survivors. The program was imbedded into existing telephone cancer information and support services delivered by Australian state-based Cancer Councils (CC). We report here the reach, effectiveness, adoption, implementation, and maintenance of the program.

METHODS

In this phase IV study (single-group, pre-post design) participants - survivors of any type of cancer, following treatment with curative intent - received up to 12 nurse/allied health professional-led telephone health coaching calls over 6 months. Intervention delivery was grounded in motivational interviewing, with emphasis on evidence-based behaviour change strategies. Using the RE-AIM evaluation framework, primary outcomes were reach, indicators of program adoption, implementation, costs and maintenance. Secondary (effectiveness) outcomes were participant-reported anthropometric, behavioural and psychosocial variables including: weight; physical activity; dietary intake; quality-of-life; treatment side-effects; distress; and fear of cancer recurrence and participant satisfaction. Changes were evaluated using linear mixed models, including terms for timepoint (0/6 months), strata (Cancer Council), and timepoint x strata.

RESULTS

Four of 5 CCs approached participated in the study. In total, 1183 cancer survivors were referred (mostly via calls to the Cancer Council telephone information service). Of these, 90.4% were eligible and 88.7% (n = 791) of those eligible consented to participate. Retention rate was 63.4%. Participants were mostly female (88%), aged 57 years and were overweight (BMI = 28.8 ± 6.5 kg/m2). Improvements in all participant-reported outcomes (standardised effect sizes of 0.1 to 0.6) were observed (p < 0.001). The program delivery costs were on average AU$427 (US$296) per referred cancer survivor.

CONCLUSIONS

This telephone-delivered lifestyle intervention, which was feasibly implemented by Cancer Councils, led to meaningful and statistically significant improvements in cancer survivors' health and quality-of-life at a relatively low cost.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12615000882527 (registered on 24/08/2015).

A uniform data set for determining outcomes in allied health primary contact services in Australia

The project aim was to develop and implement a set of metrics to capture and demonstrate the performance of newly established allied health primary contact services. Selection of the metrics and performance indicators was guided by an existing state-wide data collection system and from a review of the published literature. The metrics were refined after consultation with a working group of health service managers and clinicians. The data collection and reporting framework were developed for use in allied health primary contact services and implemented at public health facilities in Queensland, Australia. The set of metrics consists of 18 process and outcome measures. Patient-reported metrics include the global rating of change scale and patient satisfaction. Service metrics include wait times; referral source; triage category; diagnosis; occasions of service; referrals and investigations initiated; effects; care duration; discharge status; waitlist reinstatement reasons; treatment non-completion reasons; and expedited care. Safety, patient demographics and service improvement metrics were included. The metrics will enable analysis of the effectiveness of allied health primary contact services and will facilitate reporting, advocacy, service improvement, service continuity and research. The metrics are suitable for use by all providers of allied health primary contact services in hospital and primary care settings.

Process to establish 11 primary contact allied health pathways in a public health service

Objective Faced with longstanding and increasing demand for specialist out-patient appointments that was unable to be met through usual medical consultant led care, Metro North Hospital and Health Service in 2014-15 established 11 allied health primary contact out-patient models of care. Methods The models involved six different allied health professions and nine specialist out-patient departments. Results All the allied health models have been endorsed for continuation following demonstration of their contribution to managing demand on specialist out-patient services. Conclusion This paper describes key features of the allied health primary contact models of care and presents preliminary data including new case throughput, effect on wait times and enablers and challenges for clinic establishment. What is known about the topic? Allied health clinics have been demonstrated to result in high patient, referrer and consultant satisfaction, and are a cost-effective management strategy for wait list demand. In Queensland, physiotherapy-led orthopaedic clinics have been operating since 2005. What does this paper add? This paper describes the establishment of 11 allied health primary contact models of care in speciality out-patient areas including Ear, Nose and Throat, Gynaecology, Urology, Neurology, Neurosurgery, Orthopaedics and Plastic Surgery, and involving speech pathologists, audiologists, physiotherapists, occupational therapists and podiatrists as primary contact practitioners. Observations of enablers for and challenges to implementation are presented as key lessons. What are the implications for practitioners? The new allied health primary contact models of care described in this paper should be considered by health service executives, allied health leaders and specialist out-patient departments as one strategy to address unacceptably long specialist wait lists.

Implementation of simulation modelling to improve service planning in specialist orthopaedic and neurosurgical outpatient services

BACKGROUND

Advanced physiotherapist-led services have been embedded in specialist orthopaedic and neurosurgical outpatient departments across Queensland, Australia, to ameliorate capacity constraints. Simulation modelling has been used to inform the optimal scale and professional mix of services required to match patient demand. The context and the value of simulation modelling in service planning remain unclear. We aimed to examine the adoption, context and costs of using simulation modelling recommendations to inform service planning.

METHODS

Using an implementation science approach, we undertook a prospective, qualitative evaluation to assess the use of discrete event simulation modelling recommendations for service re-design and to explore stakeholder perspectives about the role of simulation modelling in service planning. Five orthopaedic and neurosurgical services in Queensland, Australia, were selected to maximise variation in implementation effectiveness. We used the consolidated framework for implementation research (CFIR) to guide the facilitation and analysis of the stakeholder focus group discussions. We conducted a prospective costing analysis in each service to estimate the costs associated with using simulation modelling to inform service planning.

RESULTS

Four of the five services demonstrated adoption by inclusion of modelling recommendations into proposals for service re-design. Four CFIR constructs distinguished and two CFIR constructs did not distinguish between high versus mixed implementation effectiveness. We identified additional constructs that did not map onto CFIR. The mean cost of implementation was AU$34,553 per site (standard deviation = AU$737).

CONCLUSIONS

To our knowledge, this is the first time the context of implementing simulation modelling recommendations in a health care setting, using a validated framework, has been examined. Our findings may provide valuable insights to increase the uptake of healthcare modelling recommendations in service planning.

Public Preferences for the Use of Taxation and Labelling Policy Measures to Combat Obesity in Young Children in Australia

Objective: Childhood obesity is a serious concern for developed and developing countries. This study aimed to assess the level of support in Australia for regulation and to assess whether systematic differences occur between individuals who support increased regulation and individuals who oppose it. Methods: An online survey (n = 563) was used to assess parental/caregiver preferences for taxation policy options and nutrition labelling designed to address the incidence of childhood obesity. Participants were parents or caregivers of young children (3 to 7 years) who were actively enrolled in an existing birth cohort study in South-East Queensland, Australia. Results: The majority of the parents (over 80%) strongly agreed or agreed with labelling food and drink with traffic light or teaspoon labelling. Support for taxation was more variable with around one third strongly supporting and a further 40% of participants equivocal about using taxation; however, a quarter strongly rejected this policy. Cluster analysis did not detect any socio-demographic differences between those who strongly supported taxation and those who did not. Conclusions: Better food labelling would be welcomed by parents to enhance food choices for their children. Taxation for health reasons would not be opposed by most parents. Implications for Public Health: Governments should consider taxation of unhealthy drinks and improved labelling to encourage healthy food purchasing.

The Efficiency of Increasing the Capacity of Physiotherapy Screening Clinics or Traditional Medical Services to Address Unmet Demand in Orthopaedic Outpatients: A Practical Application of Discrete Event Simulation with Dynamic Queuing

BACKGROUND

Hospital outpatient orthopaedic services traditionally rely on medical specialists to assess all new patients to determine appropriate care. This has resulted in significant delays in service provision. In response, Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services (OPSC) have been introduced to assess and co-ordinate care for semi- and non-urgent patients.

OBJECTIVES

To compare the efficiency of delivering increased semi- and non-urgent orthopaedic outpatient services through: (1) additional OPSC services; (2) additional traditional orthopaedic medical services with added surgical resources (TOMS + Surg); or (3) additional TOMS without added surgical resources (TOMS - Surg).

METHODS

A cost-utility analysis using discrete event simulation (DES) with dynamic queuing (DQ) was used to predict the cost effectiveness, throughput, queuing times, and resource utilisation, associated with introducing additional OPSC or TOMS ± Surg versus usual care.

RESULTS

The introduction of additional OPSC or TOMS (±surgery) would be considered cost effective in Australia. However, OPSC was the most cost-effective option. Increasing the capacity of current OPSC services is an efficient way to improve patient throughput and waiting times without exceeding current surgical resources. An OPSC capacity increase of ~100 patients per month appears cost effective (A$8546 per quality-adjusted life-year) and results in a high level of OPSC utilisation (98 %).

CONCLUSION

Increasing OPSC capacity to manage semi- and non-urgent patients would be cost effective, improve throughput, and reduce waiting times without exceeding current surgical resources. Unlike Markov cohort modelling, microsimulation, or DES without DQ, employing DES-DQ in situations where capacity constraints predominate provides valuable additional information beyond cost effectiveness to guide resource allocation decisions.

Engaging the public in healthcare decision-making: results from a Citizens' Jury on emergency care services

BACKGROUND

Policies addressing ED crowding have failed to incorporate the public's perspectives; engaging the public in such policies is needed.

OBJECTIVE

This study aimed at determining the public's recommendations related to alternative models of care intended to reduce crowding, optimising access to and provision of emergency care.

METHODS

A Citizens' Jury was convened in Queensland, Australia, to consider priority setting and resource allocation to address ED crowding. Twenty-two jurors were recruited from the electoral roll, who were interested and available to attend the jury from 15 to 17 June 2012. Juror feedback was collected via a survey immediately following the end of the jury.

RESULTS

The jury considered that all patients attending the ED should be assessed with a minority of cases diverted for assistance elsewhere. Jurors strongly supported enabling ambulance staff to treat patients in their homes without transporting them to the ED, and allowing non-medical staff to treat some patients without seeing a doctor. Jurors supported (in principle) patient choice over aspects of their treatment (when, where and type of health professional) with some support for patients paying towards treatment but unanimous opposition for patients paying to be prioritised. Most of the jurors were satisfied with their experience of the Citizens' Jury process, but some jurors perceived the time allocated for deliberations as insufficient.

CONCLUSIONS

These findings suggest that the general public may be open to flexible models of emergency care. The jury provided clear recommendations for direct public input to guide health policy to tackle ED crowding.

Yes, the government should tax soft drinks: findings from a citizens' jury in Australia

Taxation has been suggested as a possible preventive strategy to address the serious public health concern of childhood obesity. Understanding the public’s viewpoint on the potential role of taxation is vital to inform policy decisions if they are to be acceptable to the wider community. A Citizens’ Jury is a deliberative method for engaging the public in decision making and can assist in setting policy agendas. A Citizens’ Jury was conducted in Brisbane, Australia in May 2013 to answer the question: Is taxation on food and drinks an acceptable strategy to the public in order to reduce rates of childhood obesity? Citizens were randomly selected from the electoral roll and invited to participate. Thirteen members were purposively sampled from those expressing interest to broadly reflect the diversity of the Australian public. Over two days, participants were presented with evidence on the topic by experts, were able to question witnesses and deliberate on the evidence. The jurors unanimously supported taxation on sugar-sweetened drinks but generally did not support taxation on processed meats, snack foods and foods eaten/ purchased outside the home. They also supported taxation on snack foods on the condition that traffic light labelling was also introduced. Though they were not specifically asked to deliberate strategies outside of taxation, the jurors strongly recommended more nutritional information on all food packaging using the traffic light and teaspoon labelling systems for sugar, salt and fat content. The Citizens’ Jury suggests that the general public may support taxation on sugar-sweetened drinks to reduce rates of obesity in children. Regulatory reforms of taxation on sugar-sweetened drinks and improved labelling of nutritional information on product packaging were strongly supported by all members of the jury. These reforms should be considered by governments to prevent childhood obesity and the future burden on society from the consequences of obesity.