Private Hospitals In Australia Research Articles

Hospital costs for unplanned re-admissions within 30 days of hospitalisations with heart failure, Australia, 2013-2017: a retrospective cohort study.

To assess the direct hospital costs for unplanned re-admissions within 30 days of hospitalisations with heart failure in Australia; to estimate the proportion of these costs attributable to potentially preventable re-admissions. Retrospective cohort study; analysis of linked admitted patient data collections data. People admitted to hospital (all public and most private hospitals in Australia) with primary diagnoses of heart failure, 1 January 2013 - 31 December 2017, who were discharged alive and re-admitted to hospital at least once (any cause) within 30 days of discharge. Estimated re-admission costs based on National Hospital Cost Data Collection, by unplanned re-admission category based on the primary re-admission diagnosis: potentially hospital-acquired condition; recurrence of heart failure; other diagnoses related to heart failure; all other diagnoses. The first two groups were deemed the most preventable. The 165 612 eligible hospitalisations of people with heart failure during 2013-2017 (mean age, 79 years [standard deviation, 12 years]; 85 964 men [51.9%]) incurred direct hospital costs of $1881.4 million (95% confidence interval [CI], $1872.5-1890.2 million), or $376.3 million per year (95% CI, $374.5-378.1 million per year) and $11 360 per patient (95% CI, $11 312-11 408 per patient). A total of 41 125 people (24.8%) experienced a total of 58 977 unplanned re-admissions within 30 days of discharge from index admissions; these re-admissions incurred direct hospital costs of $604.4 million (95% CI, $598.2-610.5 million), or 32% of total index admission costs; that is, $120.9 million per year (95% CI, $119.6-122.1 million per year), and $14 695 per patient (95% CI, $14 535-14 856 per patient). Re-admissions with potentially hospital-acquired conditions (21 641 re-admissions) accounted for 40.1% of unplanned re-admission costs, recurrence of heart failure (18 666 re-admissions) for 35.6% of re-admission costs. Unplanned re-admissions after hospitalisations with heart failure are expensive, incurring costs equivalent to 32% of those for the initial hospitalisations; a large proportion of these costs are associated with potentially preventable re-admissions. Reducing the number of unplanned re-admissions could improve outcomes for people with heart failure and reduce hospital costs.

Long-term outcomes after hospitalization for atrial fibrillation or flutter.

Atrial fibrillation (AF) and flutter are common causes of hospitalizations but contemporary long-term outcomes following these episodes are uncertain. This study assessed outcomes up to 10 years after an acute AF or flutter hospitalization. Patients hospitalized acutely with a primary diagnosis of AF or flutter from 2008-17 from all public and most private hospitals in Australia and New Zealand were included. Kaplan-Meier methods and flexible parametric survival modelling were used to estimate survival and loss in life expectancy, respectively. Competing risk model accounting for death was used when estimating incidence of non-fatal outcomes. A total of 260 492 adults (mean age 70.5 ± 14.4 years, 49.6% female) were followed up for 1 068 009 person-years (PY), during which 69 167 died (incidence rate 6.5/100 PY) with 91.2% survival at 1 year, 72.7% at 5 years, and 55.2% at 10 years. Estimated loss in life expectancy was 2.6 years, or 16.8% of expected life expectancy. Re-hospitalizations for heart failure (2.9/100 PY), stroke (1.7/100 PY), and myocardial infarction (1.1/100 PY) were common with respective cumulative incidences of 16.8%, 11.0%, and 7.1% by 10 years. Re-hospitalization for AF or flutter occurred in 21.3% by 1 year, 35.3% by 5 years, and 41.2% by 10 years (11.6/100 PY). The cumulative incidence of patients undergoing catheter ablation of AF was 6.5% at 10 years (1.2/100 PY). Patients hospitalized for AF or flutter had high death rates with an average 2.6-year loss in life expectancy. Moreover, re-hospitalizations for AF or flutter and related outcomes such as heart failure and stroke were common with catheter ablation used infrequently for treatment, which warrant further actions.

The outcomes for women planning a VBAC at a private hospital in Australia.

Rates of cesarean birth (CBs) are steadily increasing and account for 36.7% of all births in New South Wales (NSW), with primary cesareans driving the increase. NSW Health guidelines recommend women attempt a vaginal birth after a previous CB (VBAC); however, rates of VBAC are decreasing, particularly within the private hospital setting. This study aimed to determine the rates of adverse outcomes for women who planned a VBAC (pVBAC) compared with women who planned an elective repeat CB (pERCB) at one private hospital in Sydney, Australia. This retrospective data review evaluated patient records over a 10-year period (2010-2019). Records (n = 2039) were divided into four groups: pVBAC, pVBAC + EMCB, labor + ERCB (lab + ERCB), and pERCB. The incidence of adverse maternal and neonatal outcomes is reported as counts and percentages. Regression and chi-squared tests were used to compare groups. Significance was determined at a p-value of <0.05. Overall, very low rates (N = 148, 7.3%) of women had a VBAC compared with a repeat CB at this private hospital over the 10-year period. The incidence of adverse outcomes was low regardless of study group. Outcomes differed significantly between groups for postpartum hemorrhage (pERCB seven times less likely than VBAC group) and special care nursery admission (pVBAC + EMCB is 4.6 times more likely than in the VBAC group). Overall, it is safe to attempt a VBAC at this private hospital, and labor after a cesarean should be recommended, yet very few women had a VBAC at the study site. The incidence of adverse outcomes was low compared with other published research.

Measuring the Impact of ICU Strain on Mortality, After-Hours Discharge, Discharge Delay, Interhospital Transfer, and Readmission in Australia With the Activity Index.

ICU resource strain leads to adverse patient outcomes. Simple, well-validated measures of ICU strain are lacking. Our objective was to assess whether the "Activity index," an indicator developed during the COVID-19 pandemic, was a valid measure of ICU strain. Retrospective national registry-based cohort study. One hundred seventy-five public and private hospitals in Australia (June 2020 through March 2022). Two hundred seventy-seven thousand seven hundred thirty-seven adult ICU patients. None. Data from the Australian and New Zealand Intensive Care Society Adult Patient Database were matched to the Critical Health Resources Information System. The mean daily Activity index of each ICU (census total of "patients with 1:1 nursing" + "invasive ventilation" + "renal replacement" + "extracorporeal membrane oxygenation" + "active COVID-19," divided by total staffed ICU beds) during the patient's stay in the ICU was calculated. Patients were categorized as being in the ICU during very quiet (Activity index < 0.1), quiet (0.1 to < 0.6), intermediate (0.6 to < 1.1), busy (1.1 to < 1.6), or very busy time-periods (≥ 1.6). The primary outcome was in-hospital mortality. Secondary outcomes included after-hours discharge from the ICU, readmission to the ICU, interhospital transfer to another ICU, and delay in discharge from the ICU. Median Activity index was 0.87 (interquartile range, 0.40-1.24). Nineteen thousand one hundred seventy-seven patients died (6.9%). In-hospital mortality ranged from 2.4% during very quiet to 10.9% during very busy time-periods. After adjusting for confounders, being in an ICU during time-periods with higher Activity indices, was associated with an increased risk of in-hospital mortality (odds ratio [OR], 1.49; 99% CI, 1.38-1.60), after-hours discharge (OR, 1.27; 99% CI, 1.21-1.34), readmission (OR, 1.18; 99% CI, 1.09-1.28), interhospital transfer (OR, 1.92; 99% CI, 1.72-2.15), and less delay in ICU discharge (OR, 0.58; 99% CI, 0.55-0.62): findings consistent with ICU strain. The Activity index is a simple and valid measure that identifies ICUs in which increasing strain leads to progressively worse patient outcomes.

Topical Lidocaine or Lidocaine/Diltiazem Ointment Following Rubber Band Ligation of Hemorrhoids: A Prospective Three-Armed Randomized Controlled Trial.

Rubber band ligation of hemorrhoids causes less pain than excisional hemorrhoidectomy, but many patients still experience significant post-procedure discomfort. This study aims to determine if topical lidocaine, with or without diltiazem, is more effective than placebo for analgesia following hemorrhoid banding. This is a prospective, randomized, double-blinded, placebo controlled trial. Patients were randomized to 2% lidocaine, 2% lidocaine with 2% diltiazem, or placebo ointment. This study was performed at two university public teaching hospitals and 2 private hospitals in Australia. Consecutive patients aged ≥18 years undergoing hemorrhoid banding were selected. Topical ointments were applied post-procedure 3 times daily for 5 days. Visual analogue pain score, opiate analgesia usage, and patient satisfaction were the main outcome measures. Of 159 eligible patients, 99 were randomized (33 in each group). Pain scores were reduced at 1 hour for the lidocaine (OR 4.15 [1.12-15.41] p = 0.03) and lidocaine/diltiazem groups (OR 3.85 (1.05-14.11), p = 0.04) compared with placebo. Patients in the lidocaine/diltiazem group had improved satisfaction (OR 3.82 [1.28-11.44], p = 0.02) and were more likely to recommend the procedure to others (OR 9.33 [1.07-81.72] p = 0.04). Patients in the lidocaine/diltiazem group required approximately 45% less total and in-hospital analgesia compared with placebo. There was no difference in complications between any of the groups. A cost/benefit analysis was not performed. Analgesic efficacy appeared to be short-term and the procedures were performed only in the hospital/non-ambulatory setting. Topical lidocaine improves short-term analgesia, while combination lidocaine/diltiazem is associated with both improved analgesia and patient satisfaction following hemorrhoid banding.

Leadership during airway management in the intensive care unit: A video-reflexive ethnography study.

Effective leadership is crucial to team performance within the intensive care unit. This novel study aimed to explore how staff members from an intensive care unit conceptualize leadership and what facilitators and barriers to leadership exist within a simulated workplace. It also aimed to identify factors that intersect with their perceptions of leadership. This study was underpinned by interpretivism, and video-reflexive ethnography was chosen as the methodology for the study. The use of both video recording (to capture the complex interactions occurring in the ICU) and team reflexivity allowed repeated analysis of those interactions by the research team. Purposive sampling was used to recruit participants from an ICU in a large tertiary and private hospital in Australia. Simulation groups were designed to replicate the typical clinical teams involved in airway management within the intensive care unit. Twenty staff participated in the four simulation activities (five staff per simulation group). Each group simulated the intubations of three patients with hypoxia and respiratory distress due to severe COVID-19. All 20 participants who completed the study simulations were invited to attend video-reflexivity sessions with their respective group. Twelve of the 20 participants (60%) from the simulations took part in the reflexive sessions. Video-reflexivity sessions (142 min) were transcribed verbatim. Transcripts were then imported into NVivo software for analysis. The five stages of framework analysis were used to conduct thematic analysis of the video-reflexivity focus group sessions, including the development of a coding framework. All transcripts were coded in NVivo. NVivo queries were conducted to explore patterns in the coding. The following key themes regarding participants' conceptualizations of leadership within the intensive care were identified: (1) leadership is both a group/shared process and individualistic/hierarchical; (2) leadership is communication; and (3) gender is a key leadership dimension. Key facilitators identified were: (1) role allocation; (2) trust, respect and staff familiarity; and (3) the use of checklists. Key barriers identified were: (1) noise and (2) personal protective equipment. The impact of socio-materiality on leadership within the intensive care unit is also identified.

Standardised treatment and monitoring protocol to assess safety and tolerability of bacteriophage therapy for adult and paediatric patients (STAMP study): protocol for an open-label, single-arm trial

IntroductionThere has been renewed interest in the therapeutic use of bacteriophages (phages); however, standardised therapeutic protocols are lacking, and there is a paucity of rigorous clinical trial data assessing efficacy.Methods...

Improving stroke clinical guideline adherence in an Australian hospital using a clinician-led implementation process

ABSTRACT Background Private hospitals in Australia manage 11% of acute and 48% of rehabilitation stroke admissions, yet little is known about implementation of stroke clinical guidelines in this setting. Clinical guidelines recommend that acute stroke patients be co-located in a stroke unit in a geographically defined area, rather than dispersed across the hospital. Objective To investigate post-intervention adherence to clinical guidelines for stroke management, and to explore staff barriers and facilitators to guideline implementation. Methods Observational study before-and-after local implementation of Australian stroke clinical guidelines. The primary outcome was a change in the proportion of patients who were physically co-located in an acute stroke unit. Secondary outcomes included changes in adherence to additional acute and rehabilitation guideline criteria, and staff identification of barriers and facilitators to guide implementation. Data were collected from medical record audits, health service information and staff surveys. Results Co-location in an acute stroke unit did not change significantly after guideline implementation (49% adherence pre-intervention and 54% post-intervention). Across acute and rehabilitation wards, 15% (11/72) of guideline criteria improved (p < .05). These related to assessments of swallowing and neglect, presence of a stroke care co-ordinator and occupational therapist, post-discharge care plan, provision of patient education and return to driving. Facilitators to guideline implementation included staff education, collaboration, and dissemination of user-friendly stroke policies. Conclusion Stroke clinical guideline implementation led to a favorable uptake of some criteria, yet not all. Implementation was assisted by staff education, user-friendly stroke policies and multidisciplinary team collaboration. Trial registration ANZCTR: registration number ACTRN12616000646448 (http://www.ANZCTR.org.au/ACTRN12616000646448.aspx).

Thirty-Day Unplanned Readmissions Following Hospitalisation for Atrial Fibrillation in Australia and New Zealand

Atrial fibrillation (AF) is a leading cause of hospitalisations, yet little is known about 30-day readmissions following discharge despite increasing policy focus on reducing readmissions. We assessed the rate, timing, causes and predictors of 30-day unplanned readmission following an acute and elective AF hospitalisation using population-wide data. We studied all patients hospitalised for AF from 2010 to 2015 at all public and most private hospitals in Australia and New Zealand. The main outcome measures were unplanned readmissions within 30 days of discharge, primary diagnosis associated with these readmissions, and their predictors as modelled by logistic regression. Among 301,654 patients hospitalised for AF (mean age 69.2±13.6 yrs, 55.6% female, 65.2% acute presentations), 29,750 (9.9%) experienced an unplanned readmission within 30 days with 62.6% occurring by 14 days. Unplanned readmissions occurred more frequently following an acute versus elective AF hospitalisations (12.5% vs 4.9%, p<0.001). The most common diagnoses associated with readmissions were recurrence of AF (n=9,890, 33.2%), and preventable conditions including heart failure (n=2,683, 9.0%), pneumonia (n=724, 2.4%) and acute myocardial infarction (n=510, 1.7%). A higher risk of 30-day readmission was associated with congenital cardiac/circulatory defect (OR 2.18, CI 1.44-3.30), congestive heart failure (OR 1.34, CI 1.30-1.39), and arrhythmia/conduction disorders (OR 1.25, CI 1.21-1.28). Almost 1 in 10 AF hospitalisations resulted in unplanned readmission within 30-days, mostly for AF recurrence. Improved clinical management of AF and transitional care planning are required to reduce unplanned readmissions following AF hospitalisations.

Abstract 13710: Long-Term Survival After Stroke Hospitalisations in Australia and New Zealand, 2008-2017: A Population-Based Cohort Study

Introduction: There is a paucity of national data on the long-term survival after stroke in Australia and New Zealand. We assessed survival up to 10 years, and factors associated with survival, following a stroke hospitalisation. Methods: We included all adults with the first stroke hospitalisation in the study period at all public and most private hospitals in Australia and New Zealand during 2008-2017. All-cause mortality up to December 31, 2017 were assessed by linking to regional death registries. Incidence rates of mortality and hazard ratios (HRs) were calculated. Results: 313,162 patients were included (mean ± SD age 73.0 ± 14.6 y, 52.0% were male) with ischemic stroke (175,547, 56.1%) is the most prevalent type, followed by haemorrhagic stroke (77,940, 24.9%) and unspecified stroke (59,675, 19.1%). Of these patients, 140,751 (44.9%) died in the follow-up period. The overall survival probability was 79.5% at 3 months, 73.0% at 1 year, 52.8% at 5 years and 38.8% at 9 years. The incidence rate of all-cause mortality declined with time post-stroke, from 986.6 per 1,000 person-years within 3 months to 76.7 per 1,000 person-years in 5-10 years. In the multivariable analysis, a haemorrhagic stroke (HR, 2.00; 95% confidence interval (CI), 1.97-2.03) and older age (85 years or older vs 18-54 years: aHR, 7.21; 95% CI, 7.00-7.42) was associated with a poorer prognosis. A history of congestive heart failure (aHR, 1.49; 95% CI, 1.46-1.52), acute coronary syndrome (aHR, 1.04; 95% CI, 1.01-1.07), vascular disease (aHR, 1.20; 95% CI, 1.17-1.24), and several non-cardiac conditions could also increase the mortality risk. Conclusions: Only 38.8% of stroke patients in Australia and New Zealand could survive over 9 years since their first stroke hospitalisations. Risk of death is especially high for the first few months after stroke. Further efforts are needed for those with increased risk of deaths.

Long term survival after acute myocardial infarction in Australia and New Zealand, 2009-2015: a population cohort study.

To assess long term survival and patient characteristics associated with survival following acute myocardial infarction (AMI) in Australia and New Zealand. Cohort study. All patients admitted with AMI (ICD-10-AM codes I21.0-I21.4) to all public and most private hospitals in Australia and New Zealand during 2009-2015. All-cause mortality up to seven years after an AMI. 239402 initial admissions with AMI were identified; the mean age of the patients was 69.3 years (SD, 14.3 years), 154287 were men (64.5%), and 64335 had ST-elevation myocardial infarction (STEMI; 26.9%). 7-year survival after AMI was 62.3% (STEMI, 70.8%; non-ST-elevation myocardial infarction [NSTEMI], 59.2%); survival exceeded 85% for people under 65 years of age, but was 17.4% for those aged 85 years or more. 120155 patients (50.2%) underwent revascularisation (STEMI, 72.2%; NSTEMI, 42.1%); 7-year survival exceeded 80% for patients in each group who underwent revascularisation, and was lower than 45% for those who did not. Being older (85 years or older v 18-54 years: adjusted hazard ratio [aHR], 10.6; 95% CI, 10.1-11.1) or a woman (aHR, 1.15; 95% CI, 1.13-1.17) were each associated with greater long term mortality during the study period, as was prior heart failure (aHR, 1.79; 95% CI, 1.76-1.83). Several non-cardiac conditions and geriatric syndromes common in these patients were independently associated with lower long term survival, including major and metastatic cancer, cirrhosis and end-stage liver disease, and dementia. AMI care in Australia and New Zealand is associated with high rates of long term survival; 7-year rates exceed 80% for patients under 65 years of age and for those who undergo revascularisation. Efforts to further improve survival should target patients with NSTEMI, who are often older and have several comorbid conditions, for whom revascularisation rates are low and survival after AMI poor.

The falling growth in the use of private hospitals in Australia

Australia has a rich public-private mix of financing and provision of healthcare. Since mid-2015, the higher growth in out of pocket costs relative to the growth in wages began to reduce the affordability of private healthcare and marked the start of the drop in private health insurance coverage. Using publicly available data, this paper describes the decline in growth in the utilisation of private hospital care before and after 2015. Growth in the use of elective surgery in private hospitals fell with some indication of increased waiting times in public hospitals, and evidence of doctors spending more of their time in public hospitals rather than in private practice. Private hospitals’ profitability declined, share prices of for-profit private hospital operators fell, and there is evidence of reduced capacity and a fall in long-term investment in the private hospital sector. In 2020, COVID-19 has accelerated these trends and the economic recession is likely to exacerbate reduced affordability of private healthcare. Policy responses should depend on how these changes influence access, cost and quality of care for patients.

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses.

To outline the development and effect of an audit with feedback implementation strategy that intended to increase the rate of voluntary medication error reporting by nurses. Medication errors are a serious global health issue. Audit with feedback is a widely used implementation strategy that has potential to modify nurses' reporting behaviour and improve medication error reporting rates. Quasi-experimental implementation study (fulfilling the TIDieR checklist) with two pairs of matched wards at a private hospital in Australia was conducted from March 2015-September 2016. One ward from each pair was randomised to either the intervention or control group. Nurses within intervention wards received audit with feedback on a quarterly basis over a 12-month implementation period. Control wards underwent quarterly audits only (without feedback). Feedback consisted of a one-page infographic poster, with content based on medication error data obtained from audits and the hospitals' risk management system (RiskMan). The primary outcome-rate of medication errors reported per month-was determined in both groups at pre-implementation, implementation and postimplementation phases. Differences between groups were compared using generalised linear mixed models with Poisson distribution and log link. A nonsignificant intervention effect was found for rate of medication errors reported per month. Interestingly, when combining data from both groups, a significant increasing time trend was observed for medication errors reported per month across pre-implementation and implementation phases (80% increase). The audit with feedback strategy developed in the present study did not effectively influence the voluntary reporting of medication errors by nurses. Despite the lack of intervention effects, the use of a published checklist to optimise the reporting quality of this study will contribute to the field by furthering the understanding of how to enhance audit with feedback implementation strategies for nurses.

Financing Maternity and Early Childhood Healthcare in The Australian Healthcare System: Costs to Funders in Private and Public Hospitals Over the First 1000 Days.

Background: Maternity care is a significant contributor to overall healthcare expenditure, and private care is seen as a mechanism to reduce the cost to public funders. However, public funders may still contribute to part of the cost of private care. The paper aims to quantify (1) the cost to different funders of maternal and early childhood healthcare over the first 1000 days for both women giving birth in private and public hospitals; (2) any variation in cost to different funders by birth type; and (3) the cost of excess caesarean sections in public and private hospitals in Australia. Methods: This study utilised a whole of population linked administrative dataset, and classified costs by the funding source. The mean cost to different funders for private hospital births, and public hospital births in the Australian state, Queensland are presented by time period and by birth type. The World Health Organization’s (WHO’s) C-model was used to identify the optimal caesarean section rate based upon demographic and clinical factors, and counterfactual analysis was utilised to identify the cost to different funders if caesarean section had been utilised at this rate across Australia. Results: We found that for women who gave birth in a public hospital as a public patient, the mean cost was $22474. For women who gave birth in a private hospital the mean cost was $24731, and the largest contributor was private health insurers ($11550), followed by Medicare ($7261) and individuals ($3312). Private hospital births cost government funders $10050 on average; whereas public hospital public patient births cost government funders $21723 on average and public hospital private patient births cost government funders $20899 on average. If caesarean section deliveries were reduced, public hospital funders could save $974 million and private health insurers could save $216 million. Conclusion: Private hospital births cost government funders less than public hospital births, but government funders still pay for around 40% of the cost of private hospital births. Caesarean sections, which are more frequently performed in private hospitals, are costly to all funders and reducing them could impart significant cost savings to all funders.

Identifying surgical wound care priorities from the perspectives of clinicians and health consumers in an Australian private healthcare context: a case study

Objective To identify the priorities and challenges related to surgical wound care from the perspectives of clinicians and health consumers / patients at a private hospital in Australia. Methods: Twenty-five clinical questions related to five surgical wound management topics were developed a priori and presented to four clinicians at a workshop. Questions were ranked by participating clinicians using a consensus building approach to identify the top two research priorities. One health consumer who had experience with a surgical wound was interviewed. Transcripts from the workshop and the consumer interview were analysed using a deductive approach. Results: The clinicians’ top priority questions focused on the importance of the consumer in their postoperative wound management, and the role of the wound care team in providing evidence-based care. The patient highlighted the vital role collaboration with clinicians played in the successful management of their surgical wound and continuity of care. Conclusion: Strategies to partner with consumers in the prevention of surgical wound complications can be successfully incorporated into clinical practice. Key points: What is known about the topic? While there are clear gaps in current surgical wound care practices, there is also increasing evidence that suggests wound care outcomes can improve when patients partner with clinicians. What does this paper add? Surgical wound care outcomes improved when clinicians prepared and worked with consumers using frequent education, support and assessment approaches. What are the implications for practitioners? Partnership approaches between clinicians and consumers in the prevention of surgical wound complications can be successfully incorporated into clinical practice.

P347Complications of catheter ablation for atrial fibrillation: a nation-wide study in Australia and New Zealand

Abstract Background It is important to investigate complications of catheter ablation for atrial fibrillation (AF) - an increasingly common procedure - to inform patients and guide efforts to improve procedural quality. However, clinical trials and registries are limited by selection bias, while existing population-based studies either lack nation-wide data, or fail to report post-discharge complications. The timing and impact of these complications are also poorly understood. Purpose To obtain unbiased and comprehensive estimates of complications of AF ablations using national data from Australia and New Zealand. We also evaluated the impact of in-hospital complications on the length of stay and assessed the timing of post-discharge complications. Methods We included patients aged ≥18 years undergoing catheter ablation with a primary diagnosis of AF between 2010–2015 in all public and most private hospitals in Australia and New Zealand. The primary outcome was the occurrence of major complications in-hospital or up to 30-days after discharge. We identified major complications based on a literature review and expert clinical opinion and defined these using International Classification of Diseases – 10th revision, Australian Modification diagnoses codes and Australian Classification of Health Interventions procedure codes. We determined the impact of in-hospital complications on the length of stay, adjusting for other covariates, by using negative binomial regression, and reported results as incident rate ratio (IRR) and 95% confidence intervals (CI). Time to first post-discharge complication was evaluated using Kaplan Meier survival analysis. Results A total of 20,057 AF ablations were included (mean age 62.1±11.6 y, 56.7% ≤65 years old; 29.2% female; median length of stay 1 day). Of these, major complications occurred in 6.3% procedures (4.6% occurring in-hospital and a further 2.0% occurring in the 30-day post discharge). The most common complications were bleeding or haematoma formation and perforation (primarily pericardial effusion), which accounted to 60.3% and 14.3% of all complications, respectively. Rate of procedure-related deaths was 0.1%. Occurrence of an in-hospital complication more than doubled the length of stay (IRR: 2.3, 95% CI 2.2–2.4) with complications requiring cardiac surgery (IRR 4.5, 95% CI 3.2–6.4) and vascular injuries (IRR 3.9, 95% CI 3.1–4.9) having the length of stay prolonged the most (Figure 1A). In the first-week, 67.3% of post-discharge complications had occurred, and this number reached 95% within three-weeks (Figure 1B). Conclusions Major complications after AF ablation were common. In-hospital complications doubled the length of stay. Approximately 30% of complications occurred after discharge with the risk highest in the first seven days. Efforts to reduce complications should focus on reducing the incidence of bleeding and pericardial effusions which counted for more than 75% of all complications. Acknowledgement/Funding National Heart Foundation of Australia, The Hospital Research Foundation

Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data.

To investigate inpatient rehabilitation rates after private total knee replacements (TKRs) in Australia since 2009; to quantify the contributions of hospital-, surgeon- and patient-related factors to predicting inpatient rehabilitation. Retrospective cohort study; multivariate linear regression analysis of linked, de-identified Medibank administrative claims data and hospital casemix protocol data, adjusted for patient-related characteristics. Setting, participants: 35 389 patients undergoing Medibank-funded TKRs in 170 private hospitals in Australia, 2009-2016. Hospital inpatient rehabilitation rate; relative contributions of patient- and provider-related characteristics to variation in inpatient rehabilitation rates. The overall inpatient rehabilitation rate increased from 31% in 2009 to 45% in 2016, but varied between hospitals (range, 0-100%). The reduction in mean acute length of stay during this period explained about 15% of this increase, and about 30% was explained by patient-related factors; more than half of the increase was explained by neither reduced length of stay or patient-related factors. Patient-related characteristics explained little of the variation in rates between hospitals. Rates at 27% of hospitals lay above the 95% confidence limit for the mean inpatient rehabilitation rate in private hospitals (38%), both before and after adjusting for patient-related factors. Provider characteristics explained three times as much of the variation as patient characteristics (75% v 25%); hospital-related factors made the largest contribution to variation (47%). Inpatient rehabilitation after TKR has increased in private health care during the past 8 years. Substantial variation in inpatient rehabilitation rates is not explained by patient-related factors, suggesting that some inpatient rehabilitation is low value care.

The private life of medicine: accounting for antibiotics in the ‘for-profit’ hospital setting

The looming global antibiotic crisis, and the need to curtail over-use, has been positioned variously as a medical problem, an urgent public health concern, and an issue of governance and political will. But few questions have been raised in terms of its economic drivers. Specifically, how infection management—and the problematic of antimicrobial resistance—may be deeply embedded in economic imperatives and relations of labour. Drawing on interviews with 31 health professionals (doctors, nurses, pharmacists) from a private hospital in Australia, we explore their accounts of the dynamics of care and the economic imperatives in (and beyond) infection management. We argue that market-driven forces create a distinct set of obligations that could undermine the local and global antibiotic optimisation agenda. Given the increasingly privatised landscape of healthcare in Australia and internationally, exploring the nexus of economics and practice will be vital in retaining antibiotics for the future.

Current practice and opinions of hospital pharmacists regarding their role in the screening, prevention and treatment of delirium.

Background An interdisciplinary approach is fundamental for effective prevention and treatment of delirium. Pharmacists could play a role in identifying and resolving medication-related delirium. However, little is known about their role in delirium care. Objective The main purpose of this survey was to assess the current practice and opinions of pharmacists concerning their involvement in screening, prevention and treatment of delirium. Setting Pharmacists in public and private hospitals in Australia. Method A cross-sectional survey was conducted using a pilot tested web-based questionnaire which was distributed primarily via a link in the electronic newsletter of the Society of Hospital Pharmacists of Australia. Main outcome measure Number and proportion of respondents answering questions related to the practice and perceptions of pharmacists in delirium management. Results Responses from 106 pharmacists were included in the analysis. Most respondents believed that pharmacists could play a role in prevention (92%) and screening (62%) of patients for delirium. However, in practice only 8% of pharmacists reported that they had ever screened a patient for delirium using a validated tool and 79% indicated that pharmacists were never or rarely involved in delirium treatment. When pharmacists did make recommendations half of the respondents said that pharmacists' recommendations were frequently or always accepted by the delirium treating teams. Conclusion Hospital pharmacists are underutilised in the prevention and management of delirium. Strategies to increase their involvement in the prevention and management of delirium should be implemented.

Procurement in public & private hospitals in Australia and Costa Rica – a comparative case study

This article summarizes exploratory research conducted on supply chain management practices in public hospital systems in the Australian State of Victoria and in Costa Rica. Victoria is the site of a clearly articulated (centralized) supply chain strategy as opposed to Costa Rica, where there is a strong presence of government procurement rules but no such articulated strategy. Importantly, both systems have mixed governance structures (public vs private) and had a willingness to share information pertaining to their purchasing practices. Relatively open-ended interviews, analyzed utilizing MAXQDA 11, allowed us to scrutinize the influence of public policy, supply chain integration, supply chain/clinician collaboration, value analysis teams and group purchasing. We found that centralization of procurement was prevalent in public hospitals in both countries, with more regional centralization in Victoria, Australia due to its size. Also, Private hospital systems are encouraged to take advantage of the centralized procurement policy of the government in both the countries. While standardization was achieved in both countries by better integrating procurement and information technology functions, collaboration between clinicians led to more standardization.