South Wales Public Hospitals Research Articles

Morbidity and mortality outcomes of patients requiring isolated tricuspid valve surgery: a retrospective cohort study of 537 patients in New South Wales between 2002 and 2018

ObjectivesThe aim of the study was to evaluate mortality and morbidity outcomes following open-heart isolated tricuspid valve surgery (TVSx) with medium to long-term follow-up.DesignRetrospective cohort study.SettingNew South Wales public and...

Increased patient, public involvement in locality planning - the use of patient’s narratives to support service design and continuous improvement – An evaluation from the Northwest of England

People’s narratives on their experience of health and social care can be powerful drivers for change however, Ledema (2012) found that most patients and family members felt that the health service incident disclosure rarely met their needs and expectations (1). For people to feel confident in sharing the experiences they also need to be assured that the sharing of their stories will lead to change (2).
 Rochdale is a multi-ethnic (1 in 5 of the population coming from a black or minority background) locality within Greater Manchester. Around a quarter of local people have at least one or more long term conditions and a third of residents live within 10% of the most deprived neighbourhoods nationally (3). As part of the development of a system and place-based approach, Rochdale has developed system wide learning events. These events bring together partners from across NHS, local authorities, voluntary, community and faith sectors and communities. The uniqueness of these events is that they are led by a narrative of experience of services. A person, carer, or family who have had complex experience within services is invited and supported to share their story at a themed event. Then the patient’s story is contextualised within the wider system to provide an understanding of how services can support care, where gaps exist, where there are opportunities for integration, and where there are areas that require improvement. Linking the actualities of people's experience of service to the quality improvement programme is an important feature, as are the resulting action plans which are monitored and reported through the integrated boards. To ensure agreed on plans progress and as their impact on quality improvement is realised a co-production philosophy is adopted and the events are seen as a journey rather than one off event.
 Development of the evaluation approach has been used to grow and advance the events as this has enabled the impact of the events to be monitored and the events themselves to be modified and improved to ensure that they provide a unique and valuable resource in the boroughs journey to meaningful and impactful integration, which is based on peoples experience and centred on reducing the inequalities that people across the system.
 1)Piper, D., Iedema, R., Gray, J., Verma, R., Holmes, L., & Manning, N. (2012). Utilizing experience-based co-design to improve the experience of patients accessing emergency departments in New South Wales public hospitals: an evaluation study. Health services management research, 25(4), 162-172.
 2)Hanna, E., & Robert, G. (2021). Understanding amputation care in England and Scotland: a qualitative exploration of patient stories posted on an online patient feedback site. Disability and Rehabilitation, 1-9.
 3)Rochdale Borough Council (2020) Co-operating for better health and well-being Rochdale Borough -Locality Plan 2020-2024 retrieved https://www.rochdale.gov.uk/downloads/file/879/rochdale-borough-locality-plan

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals

BackgroundInternational evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).MethodsWe conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017–2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors.ResultsOf 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45–0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients.ConclusionOur findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

Budget impact analysis of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in New South Wales Hospitals

BackgroundIn hospitals, catheter acquired urinary tract infection causes significant resource waste and discomfort among admitted patients. An intervention for reducing indwelling catheterisations - No-CAUTI - was trialled across four hospitals in New South Wales, Australia. No-CAUTI includes: train-the-trainer workshops, site champions, compliance audits, and point prevalence surveys. The trial showed reductions on usual care catheterisation rates at 4- and 9-month post-intervention. This result was statistically non-significant; and post-intervention catheterisation rates rebounded between 4 and 9 months. However, No-CAUTI showed statistically significant catheterisation decreases for medical wards, female patients and for short-term catheterisations. This study presents a budget impact analysis of a projected five year No-CAUTI roll out across New South Wales public hospitals, from the cost perspective of the New South Wales Ministry of Health.MethodsBudget forecasts were made for five year roll outs of: i) No-CAUTI; and ii) usual care, among all public hospitals in New South Wales hosting overnight stays (n=180). The roll out design maintains intervention effectiveness with ongoing workshops, quality audits, and hospital surveys. Forecasts of catheterisations, procedures and treatments were modelled on No-CAUTI trial observations. Costs were sourced from trial records, the Medical Benefits Scheme, the Pharmaceutical Benefits Scheme and public wage awards. Cost and parameter uncertainties were considered with sensitivity scenarios.ResultsThe estimated five-year No-CAUTI roll-out cost was $1.5 million. It had an overall budget saving of $640,000 due to reductions of 100,100 catheterisations, 33,300 urine tests and 6,700 antibiotics administrations. Non-Metropolitan hospitals had a net saving of $1.2 million, while Metropolitan hospitals had a net cost of $0.54 million.ConclusionsCompared to usual care, NO-CAUTI is expected to realise overall budget savings and decreases in catheterisations over five years. These findings allow a consideration of the affordability of a wide implementation.Trial registrationRegistered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000090314). First registered 17 January 2017, retrospectively. First enrolment, 15/11/2016.

Rates of Low-Value Service in Australian Public Hospitals and the Association With Patient Insurance Status

Low-value services have limited or no benefit to patients. Rates of low-value service in public hospitals may vary by patient insurance status, given that there may be different financial incentives for treatment of privately insured patients. To assess the variation in rates of 5 low-value services performed in Australian public hospitals according to patient funding status (ie, private or public). This retrospective cross-sectional study analyzed New South Wales public hospital data from January 2013 to June 2018. Patients included in the sample were over age 18 years and eligible to receive low-value services based on diagnoses and concomitant procedures. Data analysis was conducted from June to December 2020. Hospital-specific rates of low-value knee arthroscopic debridement, vertebroplasty for osteoporotic spinal fractures, hyperbaric oxygen therapy, oophorectomy with hysterectomy, and laparoscopic uterine nerve ablation for chronic pelvic pain were measured. For each measure, rates within each public hospital were compared by patient funding status descriptively and using multilevel models. A total of 219 862 inpatients were included in analysis from 58 public hospitals across the 5 measures. A total of 38 365 (22 904 [59.7%] women; 12 448 [32.4%] aged 71-80 years) were eligible for knee arthroscopic debridement for osteoarthritis; 2520 (1924 [76.3%] women; 662 [26.3%] aged 71-80 years), vertebroplasty for osteoporotic spinal fractures; 162 285 (82 046 [50.6%] women; 28 255 [17.4%] aged 61-70 years), hyperbaric oxygen therapy; 15 916 (7126 [44.8%] aged 41-50 years), oophorectomy with hysterectomy; and 776 (327 [42.1%] aged 18-30 years), uterine nerve ablation for chronic pelvic pain. Overall rates of low-value services varied considerably between measures, with the lowest rate for hyperbaric oxygen therapy (0.3 procedures per 1000 inpatients [47 of 158 220 eligible inpatients]) and the highest for vertebroplasty (30.8 procedures per 1000 eligible patients [77 of 2501 eligible inpatients]). There was significant variation in rates between hospitals, with a few outlying hospitals (ie, <10), particularly for knee arthroscopy (range from 1.8 to 21.0 per 1000 eligible patients) and vertebroplasty (range from 13.1 to 70.4 per 1000 eligible patients), with higher numerical rates of low-value services among patients with private insurance than for those without. However, there was no association overall between patient insurance status and low-value services. Overall differences in rates among those with and without private insurance by individual procedure type were not statistically significant. There was significant variation in rates of low-value services in public hospitals. While there was no overall association between private insurance and rate of low-value services, private insurance may be associated with low-value service rates in some hospitals. Further exploration of factors specific to local hospitals and practices are needed to reduce this unnecessary care.

\u201cThis is streets ahead of what we used to do\u201d: staff perceptions of virtual clinical pharmacy services in rural and remote Australian hospitals

BackgroundThe use of medications is the most common intervention in healthcare. However, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. A Virtual Clinical Pharmacy Service (VCPS) was introduced in rural and remote New South Wales public hospitals to support safe and effective use of medications. In this model clinical pharmacy services are delivered via a telehealth cart at the patient’s bedside and through electronic medical and pharmaceutical record systems. The aim of this research was to understand healthcare staff perspectives of the VCPS and identify areas for improvement.MethodsA qualitative approach informed by Appreciative Inquiry was used to investigate healthcare staff perceptions of the VCPS. Focus group discussions (n = 15) with hospital staff and medical officers were conducted via videoconference at each study site. Focus groups explored issues, benefits and barriers 3 months after service implementation. Transcribed data were analysed using thematic analysis and team discussion to synthesise themes.ResultsFocus group participants identified the value of the VCPS to patients, to the health service and to themselves. They also identified enhancements to increase value for each of these groups. Perceived benefits to patients included access to specialist medication advice and improved medication knowledge. Staff valued access to an additional, trusted workforce who provided back-up and guidance. Staff also reported confidence in improved patient safety and identification of medication errors. Enhanced compliance with antimicrobial stewardship and hospital accreditation standards were beneficial to the health service. Suggested improvements included extending virtual service hours and widening patient eligibility to include aged care patients.ConclusionsThe VCPS brought a positive, collegiate culture regarding medications. Healthcare staff perceived the VCPS was effective and an efficient way for the health service to supply pharmacy services to smaller hospitals. The ease of use, model of delivery, availability, local knowledge and responsiveness of highly skilled pharmacists was the key to user satisfaction.Trial registrationANZCTR ACTRN12619001757101, 11/12/2019.

Factors associated with admission of children to an intensive care unit and readmission to hospital within 28 days of discharge: A population-based study.

Hospital readmissions within 28 days are an important performance measurement of quality and safety of health care. The aims of this study were to examine the rates, trends and characteristics of paediatric intensive care unit admissions, and factors associated with readmissions to hospital within 28 days of discharge. This retrospective, population-based record linkage study included all children ≥28 days and <16 years old admitted to an intensive care unit (ICU) in a New South Wales (NSW) public hospital from 2004 to 2013. Data were sourced from the NSW Admitted Patients Data Collection and the NSW Registry of Births, Deaths and Marriages, Death Registration. We identified 21 200 ICU admissions involving 17 130 children. Admissions increased by 24% over the study period with the greatest increase attributed to respiratory and musculoskeletal conditions. A higher proportion of children were <5 years, male, lived in major cities, were publicly insured and had chronic conditions. The median length of ICU stay was 42 h and overall hospital stay was 7 days. There were 905 deaths, two-thirds during the index admission with the leading causes being injuries, cancer and infections. Twenty-three per cent of ICU admissions were readmitted to hospital within 28 days of discharge. Associated independent factors were younger age, longer index hospital stay and emergency index admission. Children with chronic conditions of cancer and genitourinary disorders were more likely to be readmitted. Identification of complex chronic conditions, consideration of long-term health planning and interventions intended to reduce readmission is warranted in order to reduce the burden to families and the health-care system.

1437Rates of low value care in NSW public hospitals: variation between public and private inpatients

Abstract Background Low value care (LVC) services have limited or no benefit to patients, and curtailing LVC can curb unnecessary spending and improve the quality of care. Some public hospitals in Australia have financial incentives to perform procedures for patients with private health insurance, yet little is known if there are differences in LVC between public and private patients. Methods We performed a retrospective analysis of New South Wales public hospital data from January 2013 to June 2018. We measured hospital-specific rates of five LVC services and compared rates within each public hospital by patient funding status (private or public), descriptively and using random-slope multilevel models. Results Overall rates of LVC varied between services, ranging from 0.3 to 30.8 procedures per 1,000 eligible patients for hyperbaric oxygen therapy and vertebroplasty, respectively. There was large variation in rates of the LVC services between hospitals, and a few hospitals had higher rates of LVC among private than public patients. However, we found no consistent association between patient funding status and LVC services: private patients had lower rates of knee arthroscopic debridement than public patients (aOR:0.56) and higher rates of low value vertebroplasty for osteoporotic spinal fractures (aOR:1.08), hyperbaric oxygen therapy (aOR:1.53) and oophorectomy (aOR:1.77); all statistically non-significant. Conclusions Private patient funding may contribute to LVC in some public hospitals, but it was not consistently associated with higher rates of the five LVC services measured. Key messages Reducing LVC services requires investigating the role of health-system factors at both the global- and local-level.

Towards healthier food choices for hospital staff and visitors: impacts of a healthy food and drink policy implemented at scale in Australia.

To determine the impact of a healthy food and drink policy on hospital staff and visitors' food purchasing behaviours, and their awareness and support for the changes introduced. Two repeated cross-sectional surveys, consisting of intercept interviews and observations of food items purchased, were conducted before (March-July 2018) and after (April-June 2019) the target date for implementation of thirteen food and drink practices (31 December 2018). Food purchases were coded as 'Everyday' (healthy) or 'Occasional' (unhealthy). Ten randomly selected New South Wales public hospitals, collection sites including hospital entrances and thirteen hospital cafés/cafeterias. Surveys were completed by 4808 hospital staff and visitors (response rate 85 %). The majority were female (63 %), spoke English at home (85 %) and just over half had completed tertiary education (55 %). Significant increases from before to after the implementation target date were found for policy awareness (23 to 42 %; P < 0·0001) and support (89 to 92 %; P = 0·01). The proportion of 'Everyday' food purchases increased, but not significantly (56 to 59 %; P = 0·22); with significant heterogeneity between outlets (P = 0·0008). Overall, younger, non-tertiary-educated adults, visitors and those that spoke English at home were significantly less likely to purchase 'Everyday' food items. Support was also significantly lower in males. The findings provide evidence of strong policy support, an increasing awareness of related changes and a trend towards increased 'Everyday' food purchasing. Given the relatively early phase of policy implementation, and the complexity of individual food purchasing decisions, longer-term follow-up of purchasing behaviour is recommended following ongoing implementation efforts.

Reduction of in-hospital cardiac arrest rates in intensive care-equipped New South Wales hospitals in association with implementation of Between the Flags rapid response system.

The NSW Clinical Excellence commission introduced the 'Between the Flags' programme, in response to the death of a young patient, as a system-wide approach for early detection and management of the deteriorating patient in all NSW hospitals. The impact of BTF implementation on the 35 larger hospitals with intensive care units (ICU) has not been reported previously. To assess the impact of 'Between the Flags' (BTF), a two-tier rapid response system across 35 hospitals with an ICU in NSW, on the incidence of in-hospital cardiac arrests and the incidence and outcome of patients admitted to an ICU following cardiac arrest and rapid response team activation. This is a prospective observational study of the BTF registry (August 2010 to June 2016) and the Australian and New Zealand Intensive Care Society Adult Patient Database (January 2008 to December 2016) in 35 New South Wales public hospitals with an ICU. The primary outcome studied was the proportion of in-hospital cardiac arrests. Secondary outcomes included changes in the severity of illness and outcomes of cardiac arrest admissions to the ICU and changes in the volume of rapid response calls. The cardiac arrest rate per 1000 hospital admissions declined from 0.91 in the implementation period to 0.70. Propensity score analysis showed significant declines in ICU and hospital mortality and length of stay for cardiac arrest patients admitted to the ICU (all P < 0.001). The BTF programme was associated with a significant reduction in cardiac arrests in hospitals and ICU admissions secondary to cardiac arrests in 35 NSW hospitals with an ICU.

Inequalities in end-of-life palliative care by country of birth in New South Wales, Australia: a cohort study.

Objective This study investigated variation in in-hospital palliative care according to the decedent's country of birth. Methods A retrospective cohort study was performed of 73469 patients who died in a New South Wales public hospital between July 2010 and June 2015 and were diagnosed with a palliative care-amenable condition. Differences in receipt of palliative care by country of birth were examined using multilevel logistic regression models adjusted for confounding. Results In this cohort, 26444 decedents received palliative care during their last hospital stay. In the adjusted analysis, 40% rate differences (median odds ratio 1.39; 95% confidence interval 1.31-1.51) were observed in receipt of palliative care between country of birth groups. Conclusions There are differences in in-hospital palliative care at the end of life between population groups born in different countries living in Australia. The implementation of culturally sensitive palliative care programs may help reduce these inequalities. Further studies are needed to identify the determinants of the differences observed in this study and to investigate whether these differences persist in the community setting. What is known about the topic? International studies have reported inequities in access to palliative care between ethnic groups. What does this paper add? We observed differences in in-hospital palliative care between decedents from different countries of birth in New South Wales, Australia. These differences remained after adjusting for individual, area and hospital characteristics. What are the implications for practitioners? Implementation of culturally sensitive palliative care services and targeting groups with low rates of palliative care can reduce these inequalities and improve a patient's quality of life.

Factors related to length of stay, referral on discharge and hospital readmission for children and adolescents with anorexia nervosa.

This study examined factors related to hospital length of stay (LOS), reported referral on discharge, and hospital readmission, for children and adolescents (C&A) admitted to public hospitals for anorexia nervosa (AN), in a large health jurisdiction in Australia. Sociodemographic, illness, treatment, and hospital factors associated with LOS, reported referral to post-hospital treatment, and readmission within 28 days were analyzed for C&A with AN admitted to all New South Wales public hospitals in 2017, using median, multinomial logit and logit models. The sample comprised 289 admissions by 200 C&A aged 9-18 years with a primary or secondary diagnosis of AN. AN as a primary diagnosis and the presence of some physical and mental co-occurring conditions (e.g., malnutrition and obsessive-compulsive disorders) conferred a longer LOS. The majority of admissions were recorded being referred to primary care physicians (59.86%) and relatively small numbers to outpatient mental health services (5.54%) or outpatient eating disorder services (8.30%), with age, area socioeconomic status, and illness factors related to referral type. Male, low socioeconomic status, the presence of some co-occurring illnesses (e.g., adjustment disorder and viral infection), and rural or remote locations increased the likelihood of readmission. The findings have implications for service design, in particular the pathway to care from hospital into community for AN. Targeted interventions should consider recognizing and treating physical co-occurring illnesses at presentation to the health system, ensuring appropriate referral to community services, and providing services in socioeconomically disadvantaged and rural or remote areas.

Experiences of maternity care in New South Wales among women with mental health conditions

BackgroundHigh quality maternity care is increasingly understood to represent a continuum of care. As well as ensuring a positive experience for mothers and families, integrated maternity care is responsive to mental health needs of mothers. The aim of this paper is to summarize differences in women’s experiences of maternity care between women with and without a self-reported mental health condition.MethodsSecondary analyses of a randomized, stratified sample patient experience survey of 4787 women who gave birth in a New South Wales public hospital in 2017. We focused on 64 measures of experiences of antenatal care, hospital care during and following birth and follow up at home. Experiences covered eight dimensions: overall impressions, emotional support, respect for preferences, information, involvement, physical comfort and continuity. Multivariable logistic regression was used to compare experiences of women with and without a self-reported longstanding mental health condition.ResultsCompared to women without a condition, women with a longstanding mental health condition (n = 353) reported significantly less positive experiences by eight percentage points on average, with significant differences on 41 out of 64 measures after adjusting for age, education, language, parity, type of birth and region. Disparities were pronounced for key measures of emotional support (discussion of worries and fears, trust in providers), physical comfort (assistance, pain management) and overall impressions of care. Most women with mental health conditions (75% or more) reported positive experiences for measures related to guidelines for maternity care for women with mental illness (discussion of emotional health, healthy behaviours, weight gain). Their experiences were not significantly different from those of women with no reported conditions.ConclusionsWomen with a mental health condition had significantly less positive experiences of maternity care across all stages of care compared to women with no condition. However, for some measures, including those related to guidelines for maternity care for women with mental illness, there were highly positive ratings and no significant differences between groups. This suggests disparities in experiences of care for women with mental health conditions are not inevitable. More can be done to improve experiences of maternity care for women with mental health conditions.

Comparison of administrative data and the American College of Surgeons National Surgical Quality Improvement Program data in a New South Wales Hospital.

The National Surgical Quality Improvement Program (NSQIP) is widely used in North America for benchmarking. In 2015, NSQIP was introduced to four New South Wales public hospitals. The aim of this study is to investigate the agreement between NSQIP and administrative data in the Australian setting; to compare the performance of models derived from each data set to predict 30-day outcomes. The NSQIP and administrative data variables were mapped to select variables available in both data sets where coding may be influenced by interpretation of the clinical information. These were compared for agreement. Logistic regression models were fitted to estimate the probability of adverse outcomes within 30 days. Models derived from NSQIP and administrative data were compared by receiver operating characteristic curve analysis. A total of 2240 procedures over 21 months had matching records. Functional status demonstrated poor agreement (kappa 0.02): administrative data recorded only one (1%) patient with partial- or total-dependence as recorded by NSQIP data. The American Society of Anesthesiologists class demonstrated excellent agreement (kappa 0.91). Other perioperative variables demonstrated poor to fair agreement (kappa 0.12-0.61). Predictive model based on NSQIP data was excellent at predicting mortality but was less accurate for complications and readmissions. The NSQIP model was better in predicting mortality and complications (receiver operating characteristic curve 0.93 versus 0.87; P = 0.029 and 0.71 versus 0.64; P = 0.027). There is poor agreement between NSQIP data and administrative data. Predictive models associated with NSQIP data were more accurate at predicting surgical outcomes than those from administrative data. To drive quality improvement in surgery, high-quality clinical data are required and we believe that NSQIP fulfils this function.

Routine glucose assessment in the emergency department for detecting unrecognised diabetes: a cluster randomised trial.

To determine whether routine blood glucose assessment of patients admitted to hospital from emergency departments (EDs) results in higher rates of new diagnoses of diabetes and documentation of follow-up plans. Cluster randomised trial in 18 New South Wales public district and tertiary hospitals, 31 May 2011 - 31 December 2012; outcomes follow-up to 31 March 2016. Patients aged 18 years or more admitted to hospital from EDs. Routine blood glucose assessment at control and intervention hospitals; automatic requests for glycated haemoglobin (HbA1c ) assessment and notification of diabetes services about patients at intervention hospitals with blood glucose levels of 14mmol/L or more. New diagnoses of diabetes and documented follow-up plans for patients with admission blood glucose levels of 14mmol/L or more. Blood glucose was measured in 133837 patients admitted to hospital from an ED. The numbers of new diabetes diagnoses with documented follow-up plans for patients with blood glucose levels of 14mmol/L or more were similar in intervention (83/506 patients, 16%) and control hospitals (73/278, 26%; adjusted odds ratio [aOR], 0.83; 95% CI 0.42-1.7; P=0.61), as were new diabetes diagnoses with or without plans (intervention, 157/506, 31%; control, 86/278, 31%; aOR, 1.51; 95% CI, 0.83-2.80; P=0.18). 30-day re-admission (31% v 22%; aOR, 1.34; 95% CI, 0.86-2.09; P=0.21) and post-hospital mortality rates (24% v 22%; aOR, 1.07; 95% CI, 0.74-1.55; P=0.72) were also similar for patients in intervention and control hospitals. Glucose and HbA1c screening of patients admitted to hospital from EDs does not alone increase detection of previously unidentified diabetes. Adequate resourcing and effective management pathways for patients with newly detected hyperglycaemia and diabetes are needed. Australian New Zealand Clinical Trials Registry, ACTRN12611001007921.

Variation in the incidence and timing of diagnosis of hospital-associated venous thromboembolism using linked administrative data.

Venous thromboembolism (VTE) is a potentially preventable adverse effect of hospitalisation. Inter-hospital variation in the incidence of hospital-associated VTE (HA-VTE) and timing of diagnosis (in-hospital or post-discharge) in New South Wales public hospitals were examined. Large variations in incidence (22% risk difference) and post-discharge diagnosis (115% odds difference) were evident after adjustment for case mix, which only explained 59% and 32% of inter-hospital variation respectively. The need for improved compliance with best practice guidelines is reinforced.

The impact of telephone follow up on adverse events for Aboriginal people with chronic disease in new South Wales, Australia: a retrospective cohort study

BackgroundChronic diseases are more prevalent and occur at a much younger age in Aboriginal people in Australia compared with non-Aboriginal people. Aboriginal people also have higher rates of unplanned hospital readmissions and emergency department presentations. There is a paucity of research on the effectiveness of follow up programs after discharge from hospital in Aboriginal populations. This study aimed to assess the impact of a telephone follow up program, 48 Hour Follow Up, on rates of unplanned hospital readmissions, unplanned emergency department presentations and mortality within 28 days of discharge among Aboriginal people with chronic disease.MethodsA retrospective cohort of eligible Aboriginal people with chronic diseases was obtained through linkage of routinely-collected health datasets for the period May 2009 to December 2014. The primary outcome was unplanned hospital readmissions within 28 days of separation from any acute New South Wales public hospital. Secondary outcomes were mortality, unplanned emergency department presentations, and at least one adverse event (unplanned hospital readmission, unplanned emergency department presentation or mortality) within 28 days of separation. Logistic regression models were used to assess outcomes among Aboriginal patients who received 48 Hour Follow Up compared with eligible Aboriginal patients who did not receive 48 Hour Follow Up.ResultsThe final study cohort included 18,659 patients with 49,721 separations, of which 8469 separations (17.0, 95% confidence interval (CI): 16.7–17.4) were recorded as having received 48 Hour Follow Up. After adjusting for potential confounders, there were no significant differences in rates of unplanned readmission or mortality within 28 days between people who received or did not receive 48 Hour Follow Up. Conversely, the odds of an unplanned emergency department presentation (Odds ratio (OR) = 0.92; 95% CI: 0.85, 0.99; P = 0.0312) and at least one adverse event (OR = 0.91; 95% CI: 0.85,0.98; P = 0.0136) within 28 days were significantly lower for separations where the patient received 48 Hour Follow Up compared with those that did not receive follow up.ConclusionsReceipt of 48 Hour Follow Up was associated with both a reduction in emergency department presentations and at least one adverse event within 28 days of discharge, suggesting there may be merit in providing post-discharge telephone follow up to Aboriginal people with chronic disease.

Major inpatient surgeries and in-hospital mortality in New South Wales public hospitals in Australia: A state-wide retrospective cohort study

BackgroundSurgical interventions save lives and are important focus for health services research worldwide. Investigating variation in postoperative mortality may improve understanding of unwarranted variations and promote safety and quality in surgical care. We aimed to evaluate trends of in-hospital mortality rates among adult inpatients receiving major elective surgeries and determine the variation in mortality among New South Wales (NSW) public hospitals. Materials and methodsIn this study, we used the all-inclusive population-based NSW Admitted Patient Data from July 2001 to June 2014. We retrospectively included adult patients aged 18+ years receiving Abdominal Aortic Aneurysm (AAA) repair, Peripheral bypass, Colorectal surgeries, Joint replacement, Spinal surgeries, or Cardiac surgeries. The primary outcome was in-hospital mortality for selected surgeries. Changes in mortality rates over time and hospital standardised mortality rates were modelled using multivariate logistic regression models adjusting for case-mix factors. ResultsOver 13-year study period, the in-hospital mortality rates declined annually by 6.4% (95% Confidence Interval (CI): 4.3, 8.4) for Colorectal surgery by 5.7% (95%CI: 2.0, 9.3) for Joint replacement and by 4.2% (95%CI: 1.9, 6.4) for Cardiac surgery. After controlling for patient-level factors, little variation was observed among hospitals for in-hospital mortality. There was a greater variability for cardiac surgery compared with the other surgical groups but no outlier hospital was consistently associated with significantly higher than expected mortality rate. ConclusionsMortality has declined for major surgeries in the past 15 years. There was some variation among hospitals regarding in-hospital mortality that was mostly explained by patients demographic and admission characteristics. Our findings are reassuring for patients and contribute to knowledge that can help further improve surgical care.

The use of linked data to develop and validate measures of variation in mortality and readmissions for public reporting purposes in New South Wales, Australia

ABSTRACTObjectivesTo investigate variation across 78 New South Wales public hospitals, in mortality in the 30 days following admission and in returns to acute care (readmissions) in the 30 days following discharge for acute myocardial infarction, ischaemic stroke, heart failure, pneumonia, hip fracture surgery.&#x0D; ApproachLinked data were used to (1) construct an analytic unit – an index period of care that comprised concatenated acute, contiguous hospitalisations with the principal diagnosis of interest; (2) to capture outcomes both within the index hospital and following discharge, wherever they occurred; (3) to enhance risk adjustment with one year look back for relevant comorbidities; (4) to assess fair attribution of outcomes. A risk-standardised mortality ratio (RSMR) and a risk standardised readmission ratio (RSRR) were calculated as the ratio of the observed to the expected number events at a given hospital, by developing and validating condition specific system-level prediction models. Funnel plots identified outliers. For the RSRR, the competing risk of death was considered.&#x0D; ResultsFor both outcome indicators, sensitivity was enhanced by the use of linked data (33%-100% more deaths; 23%–32% more returns to acute care or readmissions). For mortality, RSMRs that only capture deaths in hospital, as opposed to deaths within 30 days of admission, were shown to be biased and change the outlier status of about 20% of hospitals. Including socioeconomic status in risk adjustment models altered the outlier status of about 10% of hospitals on the cusp of statistical significance but did not significantly alter the RSMRs. For returns to acute care, sensitivity analyses that included socioeconomic status in the models found there was no significant improvement in discriminatory power. For example, in the case of ischaemic stroke, the c-statistic for the model without inclusion of SES was 0.593 (0.578-0.610); inclusion of SES resulted in a c-statistic of 0.600 (0.583-0.616). There were some changes in hospital-level results but there was no clear evidence of a systematic effect on results.&#x0D; ConclusionThe risk-standardised ratio method, based on linked data, compares a hospital’s results given its case mix with an average New South Wales hospital with the same case mix. Ratio-based indicators have been reported publicly and have proven to be a valuable screening tool to identify hospitals where further investigation may be required locally.

An exploration of patient-reported experiences of aspects of integrated care in New South Wales

Introduction: Increase in complex chronic diseases, development of systematic pathways of care and specialisation of healthcare providers poses challenges to ensure coordinated and continuous care for patients. Integration of care is an objective for various healthcare systems. The aim of this study is to assess the variation in patient-reported experiences of aspects of healthcare integration in New South Wales (NSW) public hospitals. Methods: The results were drawn from 17,746 respondents to the NSW Adult Admitted Patient Survey (AAPS) [January to June 2013] and 13,230 respondents to the NSW Emergency Department Survey (EDS) [April to September 2013]. Respondents had been patients of a medium or large public hospital in the given timeframe. Analysis was carried out on a selection of approximately 25 questions from each survey that addressed relevant themes such as integration of patients into care, integration of care between healthcare professionals, integration of care within hospitals and integration of care upon arrival and discharge. Results were weighted to the hospital population of age group and stay-type. Results: Whilst all measures showed variation between hospitals, some measures had a wider range of results, such as admitted patients’ reporting that they were ‘definitely’ involved in decisions about their care and treatment [mean: 59.4%, range: 46.2% 79.9%] and Emergency Department patients’ not receiving contradictory information from Emergency Department health professionals [mean: 72.8%, range: 44.6% 86.1%]. In NSW overall, there was also variation in results related to the different themes of integrated care. Some were rated more positively (such as information-provision and communication with patients), whilst others tended to show less positive ratings, including those around involvement of the patient in the ‘treatment team’ and to some extent, the integration of care between healthcare professionals. The individual measures that were rated most positively in NSW were provision of the ‘right amount’ of information to admitted patients about the medication they were taking home [91.5% of respondents] and World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116660– http://www.ijic.org/ Emergency Department health professionals providing the ‘right amount’ of information to a patient about their condition or treatment [85.6% of respondents]. Conclusion: Patient-reported experiences of care within and across different stages of the patient pathway can provide a complementary tool in evaluating the delivery of integrated care. These findings point to issues that could be targeted to improve the delivery of integrated care within the NSW public hospital sector. Limitations: The surveys used for this study were not developed specifically with integrated care in mind. While certain questions were included with the aim of measuring integrated care, the surveys may not include all relevant measures. Suggestions for Future Research: Further assessment on how to best balance the number of patient-reported measures by aspects of integrated care remains to be done.