Application of Geographic Modeling Techniques to Quantify Spatial Access to Health Services Before and After an Acute Cardiac Event: The Cardiac ARIA Project

Background: Access to cardiac services is essential for appropriate implementation of evidence-based therapies to improve outcomes. The Cardiac Accessibility and Remoteness Index for Australia (Cardiac ARIA) aimed to derive an objective, geographic measure reflecting access to cardiac services. Methods: An expert panel defined an evidence-based clinical pathway. Using Geographic Information Systems (GIS), a numeric/alpha index was developed at two points along the continuum of care. The acute category (numeric) measured the time from the emergency call to arrival at an appropriate medical facility via road ambulance. The aftercare category (alpha) measured access to four basic services (family doctor, pharmacy, cardiac rehabilitation, and pathology services) when a patient returned to their community. Results: The numeric index ranged from 1 (access to principle referral center with cardiac catheterization service ≤ 1 hour) to 8 (no ambulance service, > 3 hours to medical facility, air transport required). The alphabetic index ranged from A (all 4 services available within 1 hour drive-time) to E (no services available within 1 hour). 13.9 million (71%) Australians resided within Cardiac ARIA 1A locations (hospital with cardiac catheterization laboratory and all aftercare within 1 hour). Those outside Cardiac 1A were over-represented by people aged over 65 years (32%) and Indigenous people (60%). Conclusion: The Cardiac ARIA index demonstrated substantial inequity in access to cardiac services in Australia. This methodology can be used to inform cardiology health service planning and the methodology could be applied to other common disease states within other regions of the world.

Impact of opening a new emergency department on healthcare service and patient outcomes : analyses based on linking ambulance, emergency and hospital databases

Background Emergency department (ED) crowding caused by access block is an increasing public health issue and has been associated with impaired healthcare delivery, negative patient outcomes and increased staff workload. Aim To investigate the impact of opening a new ED on patient and healthcare service outcomes. Methods A 24-month time series analysis was employed using deterministically linked data from the ambulance service and three ED and hospital admission databases in Queensland, Australia. Results Total volume of ED presentations increased 18%, while local population growth increased by 3%. Healthcare service and patient outcomes at the two pre-existing hospitals did not improve. These outcomes included ambulance offload time: (Hospital A PRE: 10 min, POST: 10 min, P < 0.001; Hospital B PRE: 10 min, POST: 15 min, P < 0.001); ED length of stay: (Hospital A PRE: 242 min, POST: 246 min, P < 0.001; Hospital B PRE: 182 min, POST: 210 min, P < 0.001); and access block: (Hospital A PRE: 41%, POST: 46%, P < 0.001; Hospital B PRE: 23%, POST: 40%, P < 0.001). Time series modelling indicated that the effect was worst at the hospital furthest away from the new ED. Conclusions An additional ED within the region saw an increase in the total volume of presentations at a rate far greater than local population growth, suggesting it either provided an unmet need or a shifting of activity from one sector to another. Future studies should examine patient decision making regarding reasons for presenting to a new or pre-existing ED. There is an inherent need to take a ‘whole of health service area’ approach to solve crowding issues.

The "free-factor" impact on value in health services

Purpose - This paper seeks to understand the impact of financial cost on customer value in health prevention services by comparing free government services with private fee-charging providers. This is important as there is a common belief that a free health service is of lower quality and thus lower value than a paid service. However there is no evidence to verify this notion. Design / Methodology / Approach - A large-scale online survey was administered nationwide to Australian women. The respondents were asked about the functional and emotional value derived from their service experiences. Findings - Structural equation modelling (SEM) revealed non significant relationships between fee/free services and functional and emotional value (FV/EV). The non-significant relationship with FV is contrary to the theory of price quality relationship in services. This could be attributed to consumer perceptions that the technical quality of health professionals is comparable across free and paid services. The non-significant relationship with EV could be explained by the indicators used to reflect EV. These indicators were reflective of breast screening behaviour, not breast screening services. Subsequently, it may be posited that the act of having a breast screen is sufficient for consumers to derive emotional value, regardless of the financial cost. Originality / Value - This research fills an important gap in the literature by investigating the impact of financial cost on a service that consumers use proactively(prevention), rather than reactively (treatment). Insights are provided into the impact of cost on customer value in preventive health services, which are valuable to social marketing academics, health practitioners, and governments

Health complaint commissions in Australia : time for a national approach to data collection

Health complaint statistics are important for identifying problems and bringing about improvements to health care provided by health service providers and to the wider health care system. This paper overviews complaints handling by the eight Australian state and territory health complaint entities, based on an analysis of data from their annual reports. The analysis shows considerable variation between jurisdictions in the ways complaint data are defined, collected and recorded. Complaints from the public are an important accountability mechanism and open a window on service quality. The lack of a national approach leads to fragmentation of complaint data and a lost opportunity to use national data to assist policy development and identify the main areas causing consumers to complain. We need a national approach to complaints data collection in order to better respond to patients’ concerns.

How do allied health professionals evaluate new models of care? What are we measuring and why?

The aim of this study was to identify what outcome measures or quality indicators are being used to evaluate advanced and new roles in nine allied health professions and whether the measures are evaluating outcomes of interest to the patient, the clinician, or the healthcare provider. A systematic search strategy was used. Medical and allied health databases were searched and relevant articles extracted. Relevant studies with at least 1 outcome measure were evaluated. A total of 106 articles were identified that described advanced roles, however, only 23 of these described an outcome measure in sufficient detail to be included for review. The majority of the reported measures fit into the economic and process categories. The most reported outcome related to patients was satisfaction surveys. Measures of patient health outcomes were infrequently reported. It is unclear from the studies evaluated whether new models of allied healthcare can be shown to be as safe and effective as traditional care for a given procedure. Outcome measures chosen to evaluate these services often reflect organizational need and not patient outcomes. Organizations need to ensure that high-quality performance measures are chosen to evaluate the success of new health service innovations. There needs to be a move away from in-house type surveys that add little or no valid evidence as to the effect of a new innovation. More importance needs to be placed on patient outcomes as a measure of the quality of allied health interventions.

A Survey-based Study of Knowledge of Alzheimer's Disease among Health Care Staff

Background Continued aging of the population is expected to be accompanied by substantial increases in the number of people with dementia and in the number of health care staff required to care for them. Adequate knowledge about dementia among health care staff is important to the quality of care delivered to this vulnerable population. The purpose of this study was to assess knowledge about dementia across a range of health care staff in a regional health service district. Methods Knowledge levels were investigated via the validated 30-item Alzheimer's Disease Knowledge Scale (ADKS). All health service district staff with e-mail access were invited to participate in an online survey. Knowledge levels were compared across demographic categories, professional groups, and by whether the respondent had any professional or personal experience caring for someone with dementia. The effect of dementia-specific training or education on knowledge level was also evaluated. Results A diverse staff group (N = 360), in terms of age, professional group (nursing, medicine, allied health, support staff) and work setting from a regional health service in Queensland, Australia responded. Overall knowledge about Alzheimer's disease was of a generally moderate level with significant differences being observed by professional group and whether the respondent had any professional or personal experience caring for someone with dementia. Knowledge was lower for some of the specific content domains of the ADKS, especially those that were more medically-oriented, such as 'risk factors' and 'course of the disease.' Knowledge was higher for those who had experienced dementia-specific training, such as attendance at a series of relevant workshops. Conclusions Specific deficits in dementia knowledge were identified among Australian health care staff, and the results suggest dementia-specific training might improve knowledge. As one piece of an overall plan to improve health care delivery to people with dementia, this research supports the role of introducing systematic dementia-specific education or training.

Using the Donabedian framework to examine the quality and safety of nursing service innovation

Aims and objectives To evaluate the safety and quality of nurse practitioner service using the audit framework of Structure,Process and Outcome. Background Health service and workforce reform are on the agenda of governments and other service providers seeking to contain healthcare costs whilst providing safe and effective health care to communities. The nurse practitioner service is one health workforce innovation that has been adopted globally to improve timely access to clinical care, but there is scant literature reporting evaluation of the quality of this service innovation. Design. A mixed-methods design within the Donabedian evaluation framework was used. Methods The Donabedian framework was used to evaluate the Structure, Process and Outcome of nurse practitioner service. A range of data collection approaches was used, including stakeholder survey (n=36), in-depth interviews (11 patients and 13 nurse practitioners) and health records data on service processes. Results The study identified that adequate and detailed preparation of Structure and Process is essential for the successful implementation of a service innovation. The multidisciplinary team was accepting of the addition of nurse practitioner service, and nurse practitioner clinical care was shown to be effective, satisfactory and safe from the perspective of the clinician stakeholders and patients. Conclusions This study demonstrated that the Donabedian framework of Structure, Process and Outcome evaluation is a valuable and validated approach to examine the safety and quality of a service innovation. Furthermore, in this study, specific Structure elements were shown to influence the quality of service processes further validating the framework and the interdependence of the Structure, Process and Outcome components. Relevance to clinical practice Understanding the structure and process requirements for establishing nursing service innovation lays the foundation for safe, effective and patient-centred clinical care.

Balancing values and imperatives : a study of nursing service in an ICU

There has been significant attention from the managers and purchasers of health services regarding the economic advantages that result from changes to the patterns of health care delivery in the acute hospital setting. The impact of these changes, whilst often rendering advantage at the economic management level of health care, can have different consequences for the people who deliver and the people who receive health service. This paper reports on a study that was conducted with a group of nurses to investigate the practice milieu of a critical care unit in the context of changes to health service management. Interpretive methods were used to capture the perspective of the nurses and the way they interpret the multiple factors that influence their practice and their practice environment. The findings indicate that the nurses in the study setting interpret these factors according to the influences they have on the structure, the geography and the value of their work. Explication of these findings provides a research base to inform recommendations relating to improving the practice milieu of the critical care environment.

Characteristics of culturally and linguistically diverse mental health clients

The present study examined Queensland Transcultural Mental Health Centre (QTMHC) client characteristics in order to provide a better understanding for development of future health service delivery models. Archived data that was collected for 1499 clients over two years period (2007-2009) was analysed using descriptive statistics and Chi squares. The results indicated that clients were referred from a range of sources and were generally adults. There were more women than men, who sought services. At least half of the clients had language barriers and relied on bilingual workers. Most frequently expressed mental health issues were mood disorder symptoms, followed by symptoms of schizophrenia and psychosis and anxiety. Acculturation strains and stressors were described as the most common psychosocial issues. Mental health and psychosocial issues differed for age, gender and world regions from which the CALD clients originated. The findings provided an understanding of clients who seek services at QTMHC. Various ways in which transcultural services and data bases can be further improved are discussed.

Suicidal ideation and behaviours among university students in Australia

Objective: The aim of the study was to investigate the prevalence and demographic correlates of suicidal ideation and behaviours among university students in Australia and the utilisation of mental health services by this population. Method: Suicidal ideation and behaviours and demographic variables were assessed in a population of 1,678 undergraduate students by use of a modified Suicide Ideation Scale (SIS) and questionnaire. Results: Sixty two percent of students surveyed showed some suicidal ideation and 6.6% reported one or more suicide attempts. Over half of the group who reported suicide attempts did not use any type of mental health services. Suicidal ideation was found to be highly correlated with previous use of mental health services, In examining the relationship between suicidal ideation (SI) end demographic variables, SI was not significantly different for gender or parental marital status but was related to living arrangements, racial groups, religious affiliation and father's education. Conclusions: The results suggest that a higher proportion of students reported suicidal ideation and behaviours than that documented in related studies undertaken in the USA. While these findings draw attention to a higher level of suicidal ideation in students who utilise mental health assistance, more than half of those who reported suicide attempts did not use any kind of mental health service. The study has particular implications for detecting and assisting young people with a high suicide risk within the university environment.

Diabetes health program development for Aboriginal and Torres Strait Islander women

According to Australian Health (2008), the area of endocrine, nutritional and metabolic disorders (mainly diabetes) yields the highest cause of death for Indigenous Australian women at 10.1%. Indigenous Brisbane North women’s results reiterate this with slightly higher percentages and are a cause for concern and action due to the noted levels of undiagnosed/unaware Indigenous Brisbane North women with abnormal blood glucose levels, whom participated in the research. A sub-sample of the group (N=17) were piloted to test the feasibility of method of eliciting health information on Indigenous Women within this community. This pilot study revealed the following health information regarding this group of women. 41.2% of Indigenous Brisbane North women were found to have blood glucose levels that were outside normal ranges, however only 29.4% had been diagnosed with diabetes and or endocrine abnormalities. These findings highlight that 11.8% of participants have signs indicating that they may have undiagnosed diabetes or/and pre diabetes juxtaposed to unacceptable endocrine levels compatible with health and wellness. The percentages of Indigenous Brisbane North Women whom have indicated that they have a diagnosis of diabetes have been compared to both National Indigenous peoples percentages and the national percentages for the wider Australian community (all Australians). The rate of diabetes within this population is 9 times that of the wider Australian community and 5 times that of the wider Australian Indigenous community. Data was collected from Indigenous participants on arrival and the attendance numbers of 112 women was recorded for comparison with other current health prevention wellness programs being delivered. Data was also collected through the use of specially designed culturally safe questionnaires undertaken in conjunction with health checks and health service information given to participants.

What are the health needs, familial and social problems of Thai migrants in a local community in Australia? A focus group study

This study explored the health needs, familial and social problems of Thai migrants in a local community in Brisbane, Australia. Five focus groups with Thai migrants were conducted. The qualitative data were examined using thematic content analysis that is specifically designed for focus group analysis. Four themes were identified: (1) positive experiences in Australia, (2) physical health problems, (3) mental health problems, and (4) familial and social health problems. This study revealed key health needs related to chronic disease and mental health, major barriers to health service use, such as language skills, and facilitating factors, such as the Thai Temple. We concluded that because the health needs, familial and social problems of Thai migrants were complex and culture bound, the development of health and community services for Thai migrants needs to take account of the ways in which Thai culture both negatively impacts health and offer positive solutions to problems.

The growing demand for emergency healthcare

Emergency health is a critical component of health systems; one increasingly congested from growing demand and blocked access to care. The Emergency Health Services Queensland (EHSQ) study aimed to identify the factors driving increased demand for emergency healthcare. This study examined data on patients treated by the ambulance service and Emergency Departments across Queensland. Data was derived from the Queensland Ambulance Service’s (QAS) Ambulance Information Management System and electronic Ambulance Report Form and from the Emergency Department Information System (EDIS). Data was obtained for the period 2001-02 through to 2009-10. A snapshot of users for the 2009-10 year was used to describe the characteristics of users and comparisons made with the year 2003-04 to identify trends. Per capita demand for EDs has increased by 2% per annum over the decade and for ambulance by 3.7% per annum. The growth in ED demand is most significant in more urgent triage categories with decline in less urgent patients. The growth is most prominent amongst patients suffering injuries and poisoning, amongst both men and women and across all age groups. Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people exceeds those of other backgrounds. The utilisation rates for immigrant people is less than Australian born however it has not been possible to eliminate the confounding impact of age and socioeconomic profiles. These findings contribute to an understanding of the growth in demand for emergency health. It is evident that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that congested emergency health services is due to inappropriate attendees is unsustainable. The growth in demand over the last decade reflects not only on changing demographics of the Australian population but also changes in health status, standards of acute health care and other social factors.

Utilisation of hospital emergency departments among immigrants from refugee source-countries in Queensland

Despite the increasing number of immigrants, there is a limited body of literature describing the use of hospital emergency department (ED) care by immigrants in Australia. This study aims to describe how immigrants from refugee source countries (IRSC) utilise ED care, compared to immigrants from the main English speaking countries (MESC), immigrants from other countries (IOC) and the local population in Queensland. A retrospective analysis of a Queensland state-wide hospital ED dataset (ED Information System) from 1-1-2008 to 31-12-2010 was conducted. Our study showed that immigrants are not a homogenous group. We found that immigrants from IRSC are more likely to use interpreters (8.9%) in the ED compared to IOC. Furthermore, IRSC have a higher rate of ambulance use (odds ratio 1.2, 95% confidence interval (CI) 1.2–1.3), are less likely to be admitted to the hospital from the ED (odds ratio 0.7 (95% CI 0.7–0.8), and have a longer length of stay (LOS; mean differences 33.0, 95% CI 28.8–37.2), in minutes, in the ED compared to the Australian born population. Our findings highlight the need to develop policies and educational interventions to ensure the equitable use of health services among vulnerable immigrant populations.

The Large Allen Cognitive Level Screen as an indicator for medication adherence among adults accessing community mental health services

Background: Medication remains the cornerstone treatment for mental illness. Cognition is one of the strongest predictors of non-adherence. The aim of this preliminary investigation was to examine the association between the Large Allen Cognitive Level Screen (LACLS) and medication adherence among a small sample of mental health service users to determine whether the LACLS has potential as a screening tool for capacity to manage medication regimens. Method: Demographic and clinical information was collected from a small sample of people who had recently accessed community mental health services. Participants then completed the LACLS and the Medication Adherence Rating Scale (MARS) at a single time point. The strength of association between the LACLS and MARS was examined using Spearman rank-order correlation. Results: A strong positive correlation between the LACLS and medication adherence (r = 0.71, p = 0.01) was evident. No participants reported the use of medication aids despite evidence of impaired cognitive functioning. Conclusion: This investigation has provided the first empirical evidence indicating that the LACLS may have utility as a screening instrument for capacity to manage medication adherence among this population. While promising, this finding should be interpreted with caveats given its preliminary nature.