A snapshot of Australian nurse practitioners’ extended practice activities

Introduction The Australian Nurse Practitioner Project (AUSPRAC) was initiated to examine the introduction of nurse practitioners into the Australian health service environment. The nurse practitioner concept was introduced to Australia over two decades ago and has been evolving since. Today, however, the scope of practice, role and educational preparation of nurse practitioners is well defined (Gardner et al, 2006). Amendments to specific pre-existing legislation at a State level have permitted nurse practitioners to perform additional activities including some once in the domain of the medical profession. In the Australian Capital Territory, for example 13 diverse Acts and Regulations required amendments and three new Acts were established (ACT Health, 2006). Nurse practitioners are now legally authorized to diagnose, treat, refer and prescribe medications in all Australian states and territories. These extended practices differentiate nurse practitioners from other advanced practice roles in nursing (Gardner, Chang & Duffield, 2007). There are, however, obstacles for nurse practitioners wishing to use these extended practices. Restrictive access to Medicare funding via the Medicare Benefit Scheme (MBS) and the Pharmaceutical Benefit Scheme (PBS) limit the scope of nurse practitioner service in the private health sector and community settings. A recent survey of Australian nurse practitioners (n=202) found that two-thirds of respondents (66%) stated that lack of legislative support limited their practice. Specifically, 78% stated that lack of a Medicare provider number was ‘extremely limiting’ to their practice and 71% stated that no access to the PBS was ‘extremely limiting’ to their practice (Gardner et al, in press). Changes to Commonwealth legislation is needed to enable nurse practitioners to prescribe medication so that patients have access to PBS subsidies where they exist; currently patients with scripts which originated from nurse practitioners must pay in full for these prescriptions filled outside public hospitals. This report presents findings from a sub-study of Phase Two of AUSPRAC. Phase Two was designed to enable investigation of the process and activities of nurse practitioner service. Process measurements of nurse practitioner services are valuable to healthcare organisations and service providers (Middleton, 2007). Processes of practice can be evaluated through clinical audit, however as Middleton cautions, no direct relationship between these processes and patient outcomes can be assumed.

What are the real costs of major trauma?

Background This economic evaluation reports the results of a detailed study of the cost of major trauma treated at Princess Alexandra Hospital (PAH), Australia. Methods A bottom-up approach was used to collect and aggregate the direct and indirect costs generated by a sample of 30 inpatients treated for major trauma at PAH in 2004. Major trauma was defined as an admission for Multiple Significant Trauma with an Injury Severity Score >15. Direct and indirect costs were amalgamated from three sources, (1) PAH inpatient costs, (2) Medicare Australia, and (3) a survey instrument. Inpatient costs included the initial episode of inpatient care including clinical and outpatient services and any subsequent representations for ongoing-related medical treatment. Medicare Australia provided an itemized list of pharmaceutical and ambulatory goods and services. The survey instrument collected out-of-pocket expenses and opportunity cost of employment forgone. Inpatient data obtained from a publically funded trauma registry were used to control for any potential bias in our sample. Costs are reported in Australian dollars for 2004 and 2008. Results The average direct and indirect costs of major trauma incurred up to 1-year postdischarge were estimated to be A$78,577 and A$24,273, respectively. The aggregate costs, for the State of Queensland, were estimated to range from A$86.1 million to $106.4 million in 2004 and from A$135 million to A$166.4 million in 2008. Conclusion These results demonstrate that (1) the costs of major trauma are significantly higher than previously reported estimates and (2) the cost of readmissions increased inpatient costs by 38.1%.

The status of Australian nurse practitioners : the second national census

Objectives. To profile Australian nurse practitioners and their practice in 2009 and compare results with a similar 2007 census. Methods. Self-administered questionnaire. Results. Atotal of 293 nurse practitioners responded (response rate 76.3%). The majority were female (n = 229, 81.2%); mean age was 47.3 years (s.d. = 8.1). As in 2007, emergency nurse practitioners represented the largest clinical specialty (n = 63, 30.3%). A majority practiced in a metropolitan area (n = 133, 64.3%); a decrease from 2007. Consistent with 2007, only 71.5% (n = 208) were employed as a nurse practitioner and 22.8% (n = 46) were awaiting approval for some or all of their clinical protocols. Demographic data, allocations of tasks, and patterns of practice remained consistent with 2007 results. ‘No Medicare provider number’ (n = 182, 91.0%), ‘no authority to prescribe using the Pharmaceutical Benefits Scheme’ (n = 182, 89.6%) and ‘lack of organisational support’ (n = 105, 52.2%) were reported as ‘limiting’ or ‘extremely limiting’ to practice. Conclusions. Our results demonstrate less than satisfactory uptake of the nurse practitioner role despite authorisation. Barriers constraining nurse practitioner practice reduced but remained unacceptably high. Adequate professional and political support is necessary to ensure the efficacy and sustainability of this clinical role.

Incentivising private health insurance through the income tax regime : Capitalising on behavioural models

The Australian income tax regime is generally regarded as a mechanism by which the Federal Government raises revenue, with much of the revenue raised used to support public spending programs. A prime example of this type of spending program is health care. However, a government may also decide that the private sector should provide a greater share of the nation's health care. To achieve such a policy it can bring about change through positive regulation, or it can use the taxation regime, via tax expenditures, not to raise revenue but to steer or influence individuals in its desired direction. When used for this purpose, tax expenditures steer taxpayers towards or away from certain behaviour by either imposing costs on, or providing benefits to them. Within the context of the health sector, the Australian Federal Government deploys social steering via the tax system, with the Medicare Levy Surcharge and the 30 percent Private Health Insurance Rebate intended to steer taxpayer behaviour towards the Government’s policy goal of increasing the amount of health provision through the private sector. These steering mechanisms are complemented by the ‘Lifetime Health Cover Initiative’. This article, through the lens of behavioural economics, considers the ways in which these assorted mechanisms might have been expected to operate and whether they encourage individuals to purchase private health insurance.

Validation of de-identified record linkage to ascertain hospital admissions in a cohort study

Background Cohort studies can provide valuable evidence of cause and effect relationships but are subject to loss of participants over time, limiting the validity of findings. Computerised record linkage offers a passive and ongoing method of obtaining health outcomes from existing routinely collected data sources. However, the quality of record linkage is reliant upon the availability and accuracy of common identifying variables. We sought to develop and validate a method for linking a cohort study to a state-wide hospital admissions dataset with limited availability of unique identifying variables. Methods A sample of 2000 participants from a cohort study (n = 41 514) was linked to a state-wide hospitalisations dataset in Victoria, Australia using the national health insurance (Medicare) number and demographic data as identifying variables. Availability of the health insurance number was limited in both datasets; therefore linkage was undertaken both with and without use of this number and agreement tested between both algorithms. Sensitivity was calculated for a sub-sample of 101 participants with a hospital admission confirmed by medical record review. Results Of the 2000 study participants, 85% were found to have a record in the hospitalisations dataset when the national health insurance number and sex were used as linkage variables and 92% when demographic details only were used. When agreement between the two methods was tested the disagreement fraction was 9%, mainly due to "false positive" links when demographic details only were used. A final algorithm that used multiple combinations of identifying variables resulted in a match proportion of 87%. Sensitivity of this final linkage was 95%. Conclusions High quality record linkage of cohort data with a hospitalisations dataset that has limited identifiers can be achieved using combinations of a national health insurance number and demographic data as identifying variables.

Contraceptive changes after reproductive events among Australian women born in 1973 to 1978: A longitudinal study from 1996 to 2009

Background Women change contraception as they try to conceive, space births, and limit family size. This longitudinal analysis examines contraception changes after reproductive events such as birth, miscarriage or termination among Australian women born from 1973 to 1978 to identify potential opportunities to increase the effectiveness of contraceptive information and service provision. Methods Between 1996 and 2009, 5,631 Australian women randomly sampled from the Australian universal health insurance (Medicare) database completed five self-report postal surveys. Three longitudinal logistic regression models were used to assess the associations between reproductive events (birth only, birth and miscarriage, miscarriage only, termination only, other multiple events, and no new event) and subsequent changes in contraceptive use (start using, stop using, switch method) compared with women who continued to use the same method. Results After women experienced only a birth, or a birth and a miscarriage, they were more likely to start using contraception. Women who experienced miscarriages were more likely to stop using contraception. Women who experienced terminations were more likely to switch methods. There was a significant interaction between reproductive events and time indicating more changes in contraceptive use as women reach their mid-30s. Conclusion Contraceptive use increases after the birth of a child, but decreases after miscarriage indicating the intention for family formation and spacing between children. Switching contraceptive methods after termination suggests these pregnancies were unintended and possibly due to contraceptive failure. Women’s contact with health professionals around the time of reproductive events provides an opportunity to provide contraceptive services.

Agreement between self-reported use of in vitro fertilization or ovulation induction, and medical insurance claims in Australian women aged 28–36 years

STUDY QUESTION: What is the self-reported use of in vitro fertilization (IVF) and ovulation induction (OI) in comparison with insurance claims by Australian women aged 28–36 years? SUMMARY ANSWER: The self-reported use of IVF is quite likely to be valid; however, the use of OI is less well reported. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Population-based research often relies on the self-reported use of IVF and OI because access to medical records can be difficult and the data need to include sufficient personal identifying information for linkage to other data sources. There have been few attempts to explore the reliability of the self-reported use of IVF and OI using the linkage to medical insurance claims for either treatment. STUDY DESIGN: This prospective, population-based, longitudinal study included the cohort of women born during 1973–1978 and participating in the Australian Longitudinal Study on Women's Health (ALSWH) (n = 14247). From 1996 to 2009, participants were surveyed up to five times. PARTICIPANTS AND SETTING: Participants self-reported their use of IVF or OI in two mailed surveys when aged 28–33 and 31–36 years (n = 7280), respectively. This study links self-report survey responses and claims for treatment or medication from the universal national health insurance scheme (i.e. Medicare Australia). MAIN RESULTS AND THE ROLE OF CHANCE: Comparisons between self-reports and claims data were undertaken for all women consenting to the linkage (n = 3375). The self-reported use of IVF was compared with claims for OI for IVF (Kappa, K = 0.83), oocyte collection (K = 0.82), sperm preparation (K = 0.83), intracytoplasmic sperm injection (K = 0.40), fresh embryo transfers (K = 0.82), frozen embryo transfers (K = 0.64) and OI for IVF medication (K = 0.17). The self-reported use of OI was compared with ovulation monitoring (K = 0.52) and OI medication (K = 0.71). BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION: There is a possibility of selection bias due to the inclusion criteria for participants in this study: (1) completion of the last two surveys in a series of five and (2) consent to the linkage of their responses with Medicare data. GENERALIZABILITY TO OTHER POPULATIONS: The results are relevant to questionnaire-based research studies with infertile women in developed countries. STUDY FUNDING/COMPETING INTEREST(S): ALSWH is funded by the Australian Government Department of Health and Ageing. This research is funded by a National Health and Medical Research Council Centre of Research Excellence grant.

Fertility and infertility : studies in reproductive epidemiology in Australia

Worldwide, there are few large-scale epidemiological studies on infertility. In Australia, population-based research on infertility is limited to a few small-scale studies. Therefore, the prevalence of infertility and unmet need for specialist medical advice and treatment cannot be estimated reliably. Women who have used assisted reproductive technologies (ART) are recorded in treatment registries. However, there are many infertile women who are excluded from these clinical populations because they neither seek advice nor use treatment. The thesis was based on a biopsychosocial model of health and used the methods of reproductive epidemiology to address the lack of national data on the prevalence of infertility in Australia. Firstly, numbers of births and pregnancy losses were investigated in two generations of women participating in the Australian Longitudinal Study on Women’s Health (ALSWH). The ALSWH is a broad-ranging, longitudinal examination of biological, psychological and social factors that impact on women’s health and wellbeing. Women from three age cohorts were randomly sampled from the population using the universal public health insurance (i.e., Medicare) database and ALSWH participants were representative of the female population. However, the studies in the thesis only involved data from two cohorts. The younger cohort were born in 1973-78 and completed up to four mailed surveys between 1996 (when they were aged 18-23 years, n=14247) and 2006 (28-33 years, n=9145). The mid-aged cohort were born in 1946-51 and completed four mailed surveys between 1996 (when they were aged 45-50 years n=13715) and 2004 (53-58 years, n=10905). Compared to other studies that focus on outcomes of single pregnancies, these studies included all pregnancy outcomes by developing comprehensive reproductive histories for each woman. Pregnancy outcomes included birth, miscarriage, stillbirth, termination and ectopic pregnancy. Women in the youngest cohort (born in 1973-78) were only just reaching their peak childbearing years and many (44%) had yet to report their first pregnancy outcome. Women from the mid-aged cohort (born 1946-51) had completed their reproductive lives and 92% were able to report on their lifetime pregnancy outcomes. Pregnancy losses, especially miscarriage, were common for both generations of women. Secondly, the prevalence of infertility, seeking medical advice and using treatment was identified for these two generations of women. For the older generation, the lifetime prevalence of infertility and demand for treatment was investigated in the context of the specialist medical services which became available circa 1980. By this time, however, most of these older women had already been pregnant and completed their families. For women who experienced infertility (11%), their options for advice and treatment were limited and less than half (42%) had used any treatment. More recently for the younger generation of women, who were aged 28-33 years in 2006, specialist advice and treatment were extensively available. Among women who had tried to conceive or had been pregnant (n=5936), 17% had experienced infertility and the majority (72%) were able to access medical advice. However, after seeking advice only half of these infertile women had used treatment with fertility hormones or in vitro fertilisation (IVF). Overall for infertile women aged up to 33 years, only one-third had used these treatments. Thirdly, the barriers to accessing medical advice and using treatment for infertility were identified for women aged less than 34 years. Among a community sample of infertile women aged 28-33 years (ALSWH participants), self-reported depression was found to be a barrier to accessing medical advice. The characteristics of these infertile women in the community who had (n=121) or had not (n=110) used treatment were compared to infertile women aged 27-33 years (n=59) attending four fertility clinics. Compared to infertile women in the community, living in major cities and having private health insurance were associated with early use of treatment for infertility at specialist clinics by women aged <34 years. In contrast to most clinical studies of IVF, the final study reported in the thesis took into account repeated IVF cycles and the impact of women’s individual histories on IVF outcomes. Among 121 infertile women (aged 27-46 years) who had 286 IVF cycles, older age and prolonged use of the oral contraceptive pill were associated with fewer eggs collected. Further, women in particular occupations had lower proportions of eggs fertilised normally than women in other occupational groups. These studies form the first large-scale epidemiological examination of infertility in Australia. The finding that two-thirds of women with infertility had not used treatment indicates that there is an unmet need for specialist treatment in women aged less than 34 years. However, barriers to accessing treatment prevent women using ART at a younger age when there is a higher chance of pregnancy.

A limb lost every 3 hours: can Australia reduce amputations in people with diabetes?

Recommendations to improve national diabetes-related foot disease (DRFD) care • National data collection on incidence and outcomes of DRFD. • Improved access to care, through the Medicare Benefits Schedule, for people with diabetes who have a current or past foot complication. • Standardised national model for interdisciplinary DRFD care. • National accreditation of interdisciplinary foot clinics and staff. • Subsidies for evidence-based treatments for DRFD, including medical-grade footwear and pressure off-loading devices. • Holistic diabetes care initiatives to “close the gap” on inequities in health outcomes for Aboriginal and Torres Strait Islander peoples.

Community-based asylum seekers’ use of primary health care services in Melbourne

Objective: To investigate primary health care service utilisation and health presentations among asylum seekers living in Melbourne. Design and setting: Retrospective audit of files of people who attended three Melbourne asylum-seeker health clinics between 1 July 2005 and 30 June 2006. Main outcome measures: Rates of reasons for the encounter, diagnostic tests or investigations required, treatments prescribed and referrals. Results: Data were collected from 998 consultations corresponding to 341 people. Eighty-eight per cent of visits involved people with no Medicare access, owing to their visa status. The most common reasons for the encounter were general and unspecified symptoms or problems (rate, 59.9 per 100 encounters; 95% CI, 55–65), followed by musculoskeletal conditions (27.1; 95% CI, 24–30), and psychological problems (26.5; 95% CI, 23–30). The rate of referrals was 18.3 per 100 encounters (95% CI, 16–21). Conclusions: The three clinics providing services to asylum seekers in Melbourne are delivering care to a considerable number of people with complex health needs. A substantial number of asylum seekers present to clinics with psychological and social problems. Most cannot access government-subsidised health care. This must be addressed urgently by policy change at the federal and state and territory levels.

Asylum seekers living in the community on Bridging Visa E : community sector’s response to detrimental policies

In 1997, the Australian government introduced regulations restricting work rights, income and Medicare access to asylum seekers living in the community on Bridging Visa E (BVE). These visa conditions have resulted in unacceptable hardship for asylum seekers. In response, a variety of community-based agencies have been established across Australia. This study documents and collates the experiences of some of these agencies working in Victoria. These organizations maintain a high degree of inter-agency communication and liaison, have an extensive community support network by way of volunteer work and financial assistance from philanthropic organizations and the public, and have developed successful alternative models of care for asylum seekers. However, many of the agencies have been unprepared and under-resourced for the specific legal, cultural, and health concerns common to asylum seekers on BVE. A discussion of the issues faced by the community sector in the current asylum seeker/refugee political context is presented

“As many options as there are, there are just not enough for me” : a qualitative analysis of contraceptive use and barriers to access among Australian women

There is currently little information available about reasons for contraceptive use or non-use among young Australian women and the reasons for choosing specific types of contraceptive methods. A comprehensive life course perspective of women's experiences in using and obtaining contraceptives is lacking, particularly relating to women's perceived or physical barriers to access. This paper presents an analysis of qualitative data gathered from free-text comments provided by women born between 1973 and 1978 as part of their participation in the Australian Longitudinal Study on Women's Health. The Australian Longitudinal Study on Women's Health is a large cohort study involving over 40,000 women from three age groups (aged 18-23, aged 40-45 and aged 70-75) who were selected from the database of Medicare the Australian universal health insurance system in 1995. The women have been surveyed every 3 years about their health by mailed self-report surveys, and more recently online. Written comments from 690 women across five surveys from 1996 (when they were aged 18-23 years) to 2009 (aged 31-36 years) were examined. Factors relating to contraceptive use and barriers to access were identified and explored using thematic analysis. Side-effects, method satisfaction, family timing, and hormonal balance were relevant to young women using contraception. Most women who commented about a specific contraceptive method wrote about the oral contraceptive pill. While many women were positive or neutral about their method, noting its convenience or non-contraceptive benefits, many others were concerned about adverse effects, affordability, method failure, and lack of choice. Negative experiences with health services, lack of information, and cost were identified as barriers to access. As the cohort aged over time, method choice, changing patterns of use, side-effects, and negative experiences with health services remained important themes. Side-effects, convenience, and family timing play important roles in young Australian women's experiences of contraception and barriers to access. Contrary to assumptions, barriers to contraceptive access continue to be experienced by young women as they move into adulthood. Further research is needed about how to decrease barriers to contraceptive use and minimise negative experiences in order to ensure optimal contraceptive access for Australian women.

“As many options as there are, there are just not enough for me” : a qualitative analysis of contraceptive use and barriers to access among Australian women

There is currently little information available about reasons for contraceptive use or non-use among young Australian women and the reasons for choosing specific types of contraceptive methods. A comprehensive life course perspective of women's experiences in using and obtaining contraceptives is lacking, particularly relating to women's perceived or physical barriers to access. This paper presents an analysis of qualitative data gathered from free-text comments provided by women born between 1973 and 1978 as part of their participation in the Australian Longitudinal Study on Women's Health. The Australian Longitudinal Study on Women's Health is a large cohort study involving over 40,000 women from three age groups (aged 18-23, aged 40-45 and aged 70-75) who were selected from the database of Medicare the Australian universal health insurance system in 1995. The women have been surveyed every 3 years about their health by mailed self-report surveys, and more recently online. Written comments from 690 women across five surveys from 1996 (when they were aged 18-23 years) to 2009 (aged 31-36 years) were examined. Factors relating to contraceptive use and barriers to access were identified and explored using thematic analysis. Side-effects, method satisfaction, family timing, and hormonal balance were relevant to young women using contraception. Most women who commented about a specific contraceptive method wrote about the oral contraceptive pill. While many women were positive or neutral about their method, noting its convenience or non-contraceptive benefits, many others were concerned about adverse effects, affordability, method failure, and lack of choice. Negative experiences with health services, lack of information, and cost were identified as barriers to access. As the cohort aged over time, method choice, changing patterns of use, side-effects, and negative experiences with health services remained important themes. Side-effects, convenience, and family timing play important roles in young Australian women's experiences of contraception and barriers to access. Contrary to assumptions, barriers to contraceptive access continue to be experienced by young women as they move into adulthood. Further research is needed about how to decrease barriers to contraceptive use and minimise negative experiences in order to ensure optimal contraceptive access for Australian women.

A commentary on the current and future status of educational and developmental psychology in Australia

Educational and developmental psychology faces a number of current and future challenges and opportunities in Australia. In this commentary we consider the identity of educational and developmental psychology in terms of the features that distinguish it from other specialisations, and address issues related to training, specialist endorsement, supervision and rebating under the Australian government's Medicare system. The current status of training in Australia is considered through a review of the four university programs in educational and developmental psychology currently offered, and the employment destinations of their graduates. Although the need for traditional services in settings such as schools, hospitals, disability and community organisations will undoubtedly continue, the role of educational and developmental psychologists is being influenced and to some extent redefined by advances in technology, medicine, genetics, and neuroscience. We review some of these advances and conclude with recommendations for training and professional development that will enable Australian educational and developmental psychologists to meet the challenges ahead.

The concept of congruent patient-centred care for hepatitis C management

Patient-centred care has been touted as the cornerstone of an effective and efficient primary health care system. However, primary care by its nature is a fragmented system. The system co-evolves in response to needs rather than being planned. In recent years, Medicare Locals were formed in Australia with the intention to tap into this pragmatic nature of primary care and foster health services delivery which is responsive to community and individual patient needs i.e. ‘patient-centred care’. However, it remains to be seen what and how theoretical framework/s can inform this work. For this presentation we aim to illustrate with a case study how hepatitis C is currently managed in primary care and hypothesise what a congruent model of patient-centred care for hepatitis C management could look like.