General practice coordinated chronic disease management to reduce avoidable hospital admission

Chronic disease accounts for about 80 per cent of the total disease burden in Australia, and its management accounts for 70 per cent of all current health expenditure.1 Effective prevention and management of chronic disease requires a coordinated approach between primary health care, acute care services, and the patients.2 However, what is not clear is whether improvements in primary healthcare management can have a clear benefit in the cost of care of patients with chronic disease. We recently completed a pilot study in rural Western Australia to ascertain the feasibility of a coordinated general practice-based approach to managing chronic respiratory and cardiovascular conditions, and to determine the direct cost savings to the public insurer through reduction in avoidable hospital admission. The aim of this correspondence is to share our preliminary findings and encourage debate on how such a project may be scaled up or adapted to other primary healthcare settings.

A dynamic real time scheduling methodology for the emergency department

This project constructs a scheduling solution for the Emergency Department. The schedules are generated in real-time to adapt to new patient arrivals and changing conditions. An integrated scheduling formulation assigns patients to beds and treatment tasks to resources. The schedule efficiency is assessed using waiting time and total care time experienced by patients. The solution algorithm incorporates dispatch rules, meta-heuristics and a new extended disjunctive graph formulation which provide high quality solutions in a fast time-frame for real time decision support. This algorithm can be implemented in an electronic patient management system to improve patient flow in the Emergency Department.

Interventions targeting the elderly population to reduce emergency department utilisation: A literature review

Objective High utilisation of emergency department (ED) among the elderly is of worldwide concern. This study aims to review the effectiveness of interventions targeting the elderly population in reducing ED utilisation. Methods Major biomedical databases were searched for relevant studies. Qualitative approach was applied to derive common themes in the myriad interventions and to critically assess the variations influencing interventions’ effectiveness. Quality of studies was appraised using the Effective Public Health Practice Project (EPPHP) tool. Results 36 studies were included. Nine of 16 community-based interventions reported significant reductions in ED utilisation. Five of 20 hospital-based interventions proved effective while another four demonstrated failure. Seven key elements were identified. Ten of 14 interventions associated with significant reduction on ED use integrated at least three of the seven elements. All four interventions with significant negative results lacked five or more of the seven elements. Some key elements including multidisciplinary team, integrated primary care and social care often existed in effective interventions, while were absent in all significantly ineffective ones. Conclusions The investigated interventions have mixed effectiveness. Our findings suggest the hospital-based interventions have relatively poorer effects, and should be better connected to the community-based strategies. Interventions seem to achieve the most success with integration of multi-layered elements, especially when incorporating key elements such as a nurse-led multidisciplinary team, integrated social care, and strong linkages to the longer-term primary and community care. Notwithstanding limitations in generalising the findings, this review builds on the growing body of evidence in this particular area.

Pacific Rim treaty threatens public health: Patent law and medical procedures

Doctors, surgeons, and physicians around the Pacific Rim should be concerned by the proposals revealed by WikiLeaks in the Trans-Pacific Partnership (TPP). One of the most controversial features of the TPP is the proposal to provide for patent protection in respect of medical procedures. As Public Citizen observed, ‘Health providers, including surgeons, could be liable for the methods they use to treat patients.’ The civil society group noted: ‘Essentially, except for when a surgeon uses her bare hands, surgical methods would be patentable under the U.S. proposal.’ The TPP takes a broad approach to patents and medicine; lacks appropriate safeguards; and fails to address larger questions about equity, development, and human rights. Such a measure could result in greater litigation against medical professionals; barriers to access to medical procedures for patients; and skyrocketing health costs.

Accelerated strategies in the assessment of emergency patients with possible acute coronary syndromes

This thesis synthesises advancements made in the method of assessment of emergency patients with possible acute cardiac disease and has defined new assessment strategies that supports the safe early discharge of patients at low risk for acute coronary syndromes. These important findings have informed clinicians and health services about improvements that can be made at this current time in the process of care of ED patients, and the studies have had local, national and international influence.

The doctrine of necessity and the detention and restraint of people with intellectual impairment: Is there any justification?

In Australia, the legal basis for the detention and restraint of people with intellectual impairment is ad hoc and unclear. There is no comprehensive legal framework that authorises and regulates the detention of, for example, older people with dementia in locked wards or in residential aged care, people with disability in residential services or people with acquired brain injury in hospital and rehabilitation services. This paper focuses on whether the common law doctrine of necessity (or its statutory equivalents) should have a role in permitting the detention and restraint of people with disabilities. Traditionally, the defence of necessity has been recognised as an excuse, where the defendant, faced by a situation of imminent peril, is excused from the criminal or civil liability because of the extraordinary circumstances they find themselves in. In the United Kingdom, however, in In re F (Mental Patient: Sterilisation) and R v Bournewood Community and Mental Health NHS Trust, ex parte L, the House of Lords broadened the defence so that it operated as a justification for treatment, detention and restraint outside of the emergency context. This paper outlines the distinction between necessity as an excuse and as a defence, and identifies a number of concerns with the latter formulation: problems of democracy, integrity, obedience, objectivity and safeguards. Australian courts are urged to reject the United Kingdom approach and retain an excuse-based defence, as the risks of permitting the essentially utilitarian model of necessity as a justification are too great.

A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: A randomized clinical trial

IMPORTANCE Patients with chest pain represent a high health care burden, but it may be possible to identify a patient group with a low short-term risk of adverse cardiac events who are suitable for early discharge. OBJECTIVE To compare the effectiveness of a rapid diagnostic pathway with a standard-care diagnostic pathway for the assessment of patients with possible cardiac chest pain in a usual clinical practice setting. DESIGN, SETTING, AND PARTICIPANTS A single-center, randomized parallel-group trial with blinded outcome assessments was conducted in an academic general and tertiary hospital. Participants included adults with acute chest pain consistent with acute coronary syndrome for whom the attending physician planned further observation and troponin testing. Patient recruitment occurred from October 11, 2010, to July 4, 2012, with a 30-day follow-up. INTERVENTIONS An experimental pathway using an accelerated diagnostic protocol (Thrombolysis in Myocardial Infarction score, 0; electrocardiography; and 0- and 2-hour troponin tests) or a standard-care pathway (troponin test on arrival at hospital, prolonged observation, and a second troponin test 6-12 hours after onset of pain) serving as the control. MAIN OUTCOMES AND MEASURES Discharge from the hospital within 6 hours without a major adverse cardiac event occurring within 30 days. RESULTS Fifty-two of 270 patients in the experimental group were successfully discharged within 6 hours compared with 30 of 272 patients in the control group (19.3% vs 11.0%; odds ratio, 1.92; 95% CI, 1.18-3.13; P = .008). It required 20 hours to discharge the same proportion of patients from the control group as achieved in the experimental group within 6 hours. In the experimental group, 35 additional patients (12.9%) were classified as low risk but admitted to an inpatient ward for cardiac investigation. None of the 35 patients received a diagnosis of acute coronary syndrome after inpatient evaluation. CONCLUSIONS AND RELEVANCE Using the accelerated diagnostic protocol in the experimental pathway almost doubled the proportion of patients with chest pain discharged early. Clinicians could discharge approximately 1 of 5 patients with chest pain to outpatient follow-up monitoring in less than 6 hours. This diagnostic strategy could be easily replicated in other centers because no extra resources are required.

What is shared services?

Purpose This chapter discusses the constitution of Shared Services and the value of a consensual agreement of a definition for academe and practice. It explores the operating principles and services, the concepts of internal customer and internal service, and their importance for the practitioner and research communities. Methodology/approach This chapter employed a broad review of the literature to examine Shared Services. The research team used NVivo as a tool to create a database of key articles and books to analyze the key concepts and topics. Findings There is a lack of consensus on the definition of Shared Services in the research and practitioner community. Additionally, the concept of internal customer requires greater exploration and understanding within the context of Shared Services. How Shared Services provides competitive advantage to organizations is also not well understood. Research limitations/implications This discussion provides a challenge to the research community to focus on the contributions of shared services to business management theory. This requires a consensus that is currently nonexistent, to ensure the correct use of the terminology and model. Practical implications By establishing a clearer understanding of what is Shared Services, the academic and the practitioner community, in particular, will gain greater competencies on Shared Services to support change management programs during the implementation phases and minimize implementation costs by lowering organizational and people resistance. The variants in shared services terminology create confusion which is likely to result in ambiguity during implementation and have practical implications on governance, customers and service, benefits realization and performance. Originality/value of chapter This chapter addresses the lack of agreed definition of the term Shared Services and the role of the internal customer and consequent internal service delivery.

Development and validation of the Emergency Department Assessment of Chest pain Score and 2h accelerated diagnostic protocol

Objective Risk scores and accelerated diagnostic protocols can identify chest pain patients with low risk of major adverse cardiac event who could be discharged early from the ED, saving time and costs. We aimed to derive and validate a chest pain score and accelerated diagnostic protocol (ADP) that could safely increase the proportion of patients suitable for early discharge. Methods Logistic regression identified statistical predictors for major adverse cardiac events in a derivation cohort. Statistical coefficients were converted to whole numbers to create a score. Clinician feedback was used to improve the clinical plausibility and the usability of the final score (Emergency Department Assessment of Chest pain Score [EDACS]). EDACS was combined with electrocardiogram results and troponin results at 0 and 2 h to develop an ADP (EDACS-ADP). The score and EDACS-ADP were validated and tested for reproducibility in separate cohorts of patients. Results In the derivation (n = 1974) and validation (n = 608) cohorts, the EDACS-ADP classified 42.2% (sensitivity 99.0%, specificity 49.9%) and 51.3% (sensitivity 100.0%, specificity 59.0%) as low risk of major adverse cardiac events, respectively. The intra-class correlation coefficient for categorisation of patients as low risk was 0.87. Conclusion The EDACS-ADP identified approximately half of the patients presenting to the ED with possible cardiac chest pain as having low risk of short-term major adverse cardiac events, with high sensitivity. This is a significant improvement on similar, previously reported protocols. The EDACS-ADP is reproducible and has the potential to make considerable cost reductions to health systems.

Communicating consequences with costs: A commentary on Corso et al's cost of injury

Estimating the economic burden of injuries is important for setting priorities, allocating scarce health resources and planning cost-effective prevention activities. As a metric of burden, costs account for multiple injury consequences—death, severity, disability, body region, nature of injury—in a single unit of measurement. In a 1989 landmark report to the US Congress, Rice et al1 estimated the lifetime costs of injuries in the USA in 1985. By 2000, the epidemiology and burden of injuries had changed enough that the US Congress mandated an update, resulting in a book on the incidence and economic burden of injury in the USA.2 To make these findings more accessible to the larger realm of scientists and practitioners and to provide a template for conducting the same economic burden analyses in other countries and settings, a summary3 was published in Injury Prevention. Corso et al reported that, between 1985 and 2000, injury rates declined roughly 15%. The estimated lifetime cost of these injuries declined 20%, totalling US$406 billion, including US$80 billion in medical costs and US$326 billion in lost productivity. While incidence reflects problem size, the relative burden of injury is better expressed using costs.

Disaster management in Nepal: Media engagement in the Post-2015 Framework for Disaster Risk Reduction

Nepal, as a consequence of its geographical location and changing climate, faces frequent threats of natural disasters. According to the World Bank’s 2005 Natural Disasters Hotspots Report, Nepal is ranked the 11th most vulnerable country to earthquake and 30th to flood risk. Geo-Hazards International (2011) has classified Kathmandu as one of the world’s most vulnerable cities to earthquakes. In the last four decades more than 32,000 people in Nepal have lost their lives and annual monetary loss is estimated at more than 15 million (US) dollars. This review identifies gaps in knowledge, and progress towards implementation of the Post Hyogo Framework of Action. Nepal has identified priority areas: community resilience, sustainable development and climate change induced disaster risk reduction. However, one gap between policy and action lies in the ability of Nepal to act effectively in accordance with an appropriate framework for media activities. Supporting media agencies include the Press Council, Federation of Nepalese Journalists, Nepal Television, Radio Nepal and Telecommunications Authority and community based organizations. The challenge lies in further strengthening traditional and new media to undertake systematic work supported by government bodies and the National Risk Reduction Consortium (NRRC). Within this context, the ideal role for media is one that is proactive where journalists pay attention to a range of appropriate angles or frames when preparing and disseminating information. It is important to develop policy for effective information collection, sharing and dissemination in collaboration with Telecommunication, Media and Journalists. The aim of this paper is to describe the developments in disaster management in Nepal and their implications for media management. This study provides lessons for government, community and the media to help improve the framing of disaster messages. Significantly, the research highlights the prominence that should be given to flood, landslides, lightning and earthquakes.

Examining the profile and experiences of older sub-acute patients who present to public hospital emergency departments in South East Queensland: A mixed methods approach

There is a scarcity of research that informs Interface Health Service (IHS) development. This research applied a mixed methods approach to profile older emergency department patients and patterns of health service use and to explore their ED experiences in public hospital EDs in South-East Queensland. IHS was under-utilised by older people with complex co-morbidities. Lack of communication and need identification were factors that undermined the effectiveness of IHS in reaching this cohort which highlighted a need for change.

Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study

Background There has been considerable publicity regarding population ageing and hospital emergency department (ED) overcrowding. Our study aims to investigate impact of one intervention piloted in Queensland Australia, the Hospital in the Nursing Home (HiNH) program, on reducing ED and hospital attendances from residential aged care facilities (RACFs). Methods A quasi-experimental study was conducted at an intervention hospital undertaking the program and a control hospital with normal practice. Routine Queensland health information system data were extracted for analysis. Results Significant reductions in the number of ED presentations per 1000 RACF beds (rate ratio (95 % CI): 0.78 (0.67–0.92); p = 0.002), number of hospital admissions per 1000 RACF beds (0.62 (0.50–0.76); p < 0.0001), and number of hospital admissions per 100 ED presentations (0.61 (0.43–0.85); p = 0.004) were noticed in the experimental hospital after the intervention; while there were no significant differences between intervention and control hospitals before the intervention. Pre-test and post-test comparison in the intervention hospital also presented significant decreases in ED presentation rate (0.75 (0.65–0.86); p < 0.0001) and hospital admission rate per RACF bed (0.66 (0.54–0.79); p < 0.0001), and a non-significant reduction in hospital admission rate per ED presentation (0.82 (0.61–1.11); p = 0.196). Conclusions Hospital in the Nursing Home program could be effective in reducing ED presentations and hospital admissions from RACF residents. Implementation of the program across a variety of settings is preferred to fully assess the ongoing benefits for patients and any possible cost-savings.

What does built environment research have to do with risk mitigation, resilience and disaster recovery?

One could argue that the nature of our housing stock is a key determining factor in the ability of our citizens to manage risk, be resilient to various natural and human events, and to recover from these events. Recent research has been examining current challenges posed by our housing stock and exploring potential solutions from a range of perspectives. The aim of this paper is to discuss key findings from recent built environment research in Australia to initiate cross-sectorial discussion and debate about the implications and opportunities for other sectors such as emergency management and insurance. Three recent building research projects are discussed: - Heat waves The impact of heat waves on houses and occupants, and proposed changes to building regulations, air conditioning standards and building design, to reduce risks associated with heat waves. - Net zero energy homes Exploration of the potential benefits of a strategic optimization of building quality, energy and water efficiency, and household or community level distributed energy and water services for disaster management and recovery. - Building information Mapping of the flow of information about residential buildings, and the potential for national or regional building files (in a similar manner to personal medical records) to assist all parties to make more informed decisions that impact on housing sustainability and community resilience. The paper discusses how sustainability, environmental performance and resilience are inter-related, and can be supported by building files. It concludes with a call for increased cross-sectorial collaboration to explore opportunities for a whole-of-systems approach to our built environment that addresses a range of economic and environmental challenges as well as disaster and emergency management.

Improved wound management at lower costs: A sensible goal for Australia

Chronic wounds cost the Australian health system at least US$2·85 billion per year. Wound care services in Australia involve a complex mix of treatment options, health care sectors and funding mechanisms. It is clear that implementation of evidence-based wound care coincides with large health improvements and cost savings, yet the majority of Australians with chronic wounds do not receive evidence-based treatment. High initial treatment costs, inadequate reimbursement, poor financial incentives to invest in optimal care and limitations in clinical skills are major barriers to the adoption of evidence-based wound care. Enhanced education and appropriate financial incentives in primary care will improve uptake of evidence-based practice. Secondary-level wound specialty clinics to fill referral gaps in the community, boosted by appropriate credentialing, will improve access to specialist care. In order to secure funding for better services in a competitive environment, evidence of cost-effectiveness is required. Future effort to generate evidence on the cost-effectiveness of wound management interventions should provide evidence that decision makers find easy to interpret. If this happens, and it will require a large effort of health services research, it could be used to inform future policy and decision-making activities, reduce health care costs and improve patient outcomes.