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Patients from racial/ethnic minority backgrounds can experience racism and race-based discrimination in the health system, enduring unfair and inferior treatment that negatively affects physical and mental health and well-being and may, in some cases, lead to premature and avoidable death. Racism within the health system also acts as a deterrent to health care access because individuals may choose to avoid healthcare settings for fear of repeated exposure to racism. Racism and its impacts in health are well documented and health care-related regulatory organisations and antidiscrimination commissions in Australia are the recipients of racism complaints that occur within the health system. However, the extent and nature of complaints of racism in healthcare settings (i.e. self-reported incidents of racism) and how they are managed by regulatory organisations and antidiscrimination commissions are not well understood. This paper provides a summary of existing approaches to complaints in the Australian health system related to healthcare regulatory organisations and antidiscrimination commissions. We offer recommendations for improvements to data collection and dissemination of racism complaints to better understand the nature and extent of racism and race-based discrimination in the health system, and thus inform changes to process and practices that will reduce the incidence of racism and improve health outcomes. What is known about the topic? Patient complaints of racism in the health system are received by health care-related regulatory organisations and antidiscrimination commissions. However, the extent and nature of the complaints of racism in healthcare settings and how they are managed are not well understood. What does the paper add? This paper provides a summary of existing approaches to complaints in the Australian health system related to healthcare regulatory organisations and antidiscrimination commissions. We identify ways that existing complaints processes and mechanisms can be strengthened to enhance the safety and quality of patient care. What are the implications for practitioners? Practitioners, healthcare managers and policy makers can enhance existing complaints processes and mechanisms in order to improve the collection and use of healthcare racism complaints that can inform strategies to reduce healthcare racism and improve patient care.

Objective The need for residential care services will grow significantly over the coming years as the general population in Australia continues to age. The aim of this study was to assess the adequacy of residential care services across New South Wales (NSW), Australia, in relation to the current and predicted future aging population. Method This study was a secondary data analysis. Existing datasets were compiled for analysis by creation of a temporal geodatabase, with predicted population data from 2019 to 2029 linked to corresponding geographic zones. Results Demand for operational places was over capacity in 2019, at 101.5%. From 2019 to 2029, this will grow to 120.2% of 2019 capacity by 2024 and to 135.6% by 2029. An additional 25 800 operational places will be required by 2029 to meet targets. During the previous decade of 2008–18, operational places grew by only 11 502 places. Conclusions NSW was not providing an adequate level of residential aged care and, under current allocations, this problem will worsen substantially over time, with flow-on impacts for the health sector. With aged care reform a current federal government focus, the results of this study may guide decisions that better support the provision of residential aged care. What is known about this topic? The recently completed Australian Royal Commission into aged care noted widespread system failure and highlighted the gaps in medical services that older Australians were experiencing. What does this paper add? This paper reports that demand for residential aged care places in NSW was already over capacity in 2019 and that the availability of places varies considerably across the state. Further, an additional 25 800 operational places are required by 2029 to meet government targets. If the growth rate from the past decade is maintained, this will result in a shortfall of 14 298 aged care places in NSW alone. What are the implications? Without significant increases in the current rate of growth for aged care places, the mainstream medical and health sectors will face significant additional pressures arising from unmet need in both older patients and their informal carers.

Objective Chronic pain and cardiovascular disease (CVD) have a high disease burden. This research aimed to understand whether Australian primary health networks (PHNs) are recognising the need for the prevention of these conditions by investigating what local health and service issues have been identified. Methods Separate sets of needs assessments were analysed for chronic pain and CVD for all 31 PHNs using a document analysis approach. Framework analysis was undertaken to ascertain the types of health and service issues, prevention-related issues and supporting data sources identified, as well as to quantify the number of PHNs identifying these issues. Results Fewer PHNs identified health issues for chronic pain (n = 13) compared with CVD (n = 30), with the most common being disease prevalence and burden supported by National Health Survey data. Service issues were identified by fewer than half the PHNs (n = 13 for each disease), which were largely informed by stakeholder consultation and related to service integration, service accessibility and health professional training. Prevention-related issues were frequently identified for CVD (n = 26), but not chronic pain (n = 3). Conclusions This paper highlights the need for a greater focus on chronic pain- and CVD-related issues by PHNs. This could be supported nationally by recognising chronic pain and risk factors in national datasets and PHN performance frameworks, and locally via greater stakeholder consultation to inform PHN population health planning. What is known about the topic? Chronic pain and CVD are the two leading causes of total disease burden in Australia. PHNs are well positioned to address prevention locally through population health planning, supporting primary healthcare providers, health care integration and coordination and commissioning necessary services. What does this paper add? This paper highlights gaps in data availability, the proportion of PHNs identifying local service issues for both chronic pain and CVD and health- and prevention-related issues for chronic pain. What are the implications for practitioners? Although PHNs are constrained by government priorities and funding, greater stakeholder consultation is one potentially promising strategy to overcome local data gaps to identifying and prioritising chronic pain and CVD prevention.

Objective This study determined caregivers’ evaluations of telehealth consultations for their child, preference over in-person consultations and potential cost savings by child condition, family socioeconomic status and location. Methods A survey was conducted of 2436 caregivers attending a telehealth consultation with their child for a broad group of conditions between 3 June and 25 August 2020 at a tertiary paediatric hospital in Melbourne, Australia. Results Most caregivers found telehealth consultations convenient, acceptable, safe and private, and capable of answering their questions and concerns. However, caregivers who spoke a language other than English and patients attending for behavioural and mental health, developmental or other (e.g. allied health) concerns were more likely to prefer in-person consultations over telehealth. Mean (±s.d.) reported cost savings on caregiver time were A$144.98 ± 99.04 per family per consultation, whereas mean (±s.d.) transport cost savings were A$84.90 ± 100.74 per family per consultation. Cost savings were greatest for families living in low and middle socioeconomic areas and regional or rural areas. Conclusions Paediatric telehealth video consultations were largely viewed favourably by caregivers, except for those attending for behavioural and mental health or developmental concerns. What is known about the topic? Adult consumers of telehealth consultations view them as useful, convenient and cost saving, but less is known about caregivers’ evaluations of telehealth consultations and potential cost savings for paediatric patients, and whether these differ by family location, socioeconomic status or child condition. What does this paper add? This is the first Australian paper to report on caregivers’ evaluations across a range of paediatric conditions and locations. Most caregivers found telehealth consultations convenient, safe, acceptable, able to answer their questions and concerns about their child’s health and cost saving. What are the implications for practitioners? Caregivers of children with behavioural, mental health or developmental problems were less likely to prefer telehealth over in-person consultations, so practitioners should consider providing such consultations in person.

Objective Stepped care as a model of provision of mental health services has been frequently described from clinical or health administration perspectives, but less is known about the consumer perspective of stepped models of care. Method Qualitative interviews were undertaken with 18 consumers across a range of residential mental health services in Melbourne, Australia. Interviews were designed to help understand consumers’ needs and experiences in navigating different services to meet their needs at different times in their mental health journey. Results Consumers experience fluctuations in their mental state that are best responded to by having access to a range of services, as well as to services that can respond flexibly to changing needs. Consumers do not necessarily progress through stepped care in a linear or step-up, step-down fashion. Conclusion Stepped care services need to be flexible in accommodating people along a continuum of care and responsive to where the consumer is at on their journey, rather than predetermining the trajectory of care. What is known about the topic? Stepped care has been identified as a critical component of comprehensive mental health care, bridging the gap between primary care and acute mental health services. The components of effective stepped care models have been broadly articulated, but the experience of moving through different components of care in response to changing needs has not previously been well described. What does the paper add? This paper presents consumer perspectives on a model of stepped care that is designed to respond flexibly to the changing needs of consumers, rather than representing a linear model of progress through the system. What are the implications for practitioners? Mental health services are increasingly grappling with provision of care to the ‘missing middle’: people with chronic mental illness yet not in an acute phase requiring in-patient hospital care. This paper presents a model of stepped care that responds to the fluctuating needs of consumers

Objective This study reviewed the maternity leave policies in Australian general practice speciality training and compared them to hospital-based speciality training policies. Methods Nine general practice regional training organisations’ maternity leave policies were audited and compared to 11 Australian hospital speciality training maternity leave policies. Data pertaining to each component of Cheung’s health policy analysis tool were reviewed. Results Across all specialities there was a lack of evidence-informed policy design and evidence-based goal setting. Compared with other specialities, general practice was the only speciality where trainees did not receive paid maternity leave. Conclusions This study highlights the need to improve maternity leave policies in line with evidence and best practice for both general practice and hospital-based speciality registrars. What is known about the topic? There is an increasing number of females graduating from medical degrees and planning parenting and speciality medical training simultaneously. The balance of these two roles is dependent on the policies and protocols of the training providers, who need to ensure that parenting and a medical career are compatible. What does this paper add? This paper reports on the findings of an audit of the current maternity leave policies for general practice and hospital-based medical registrar trainees in Australia. It identifies key areas within the policies that need to be addressed. What are the implications for practitioners? This paper identifies that all policies lack evidence of being evidence based in their design. This audit has demonstrated that most policies do not meet the World Health Organization’s recommendations for maternity leave. Specifically, general practice trainees are the only doctors who do not have a policy that requires paid maternity leave. However, as the training of general practice registrars moves towards being undertaken by the Royal Australian College of General Practitioners, there is an opportunity for a review of this policy so that it becomes aligned with other Australian medical registrar training policies.

Objective The aim of this study was to quantify the direct and indirect costs of asthma and allergic rhinitis (AR) for 2018 in Tasmania. Methods We used publicly available data, and Tasmanian-specific values where available, to estimate direct and indirect costs of both diseases. Direct costs included outcomes such as emergency department (ED) presentations, hospitalisations, general practice visits and medication use. Indirect costs included premature mortality and lost productivity. Results Direct health impacts for both conditions combined included 1454 ED presentations, 682 hospitalisations, 72 446 general practice visits and 7122 specialist visits. Indirect health impacts included 13 deaths and between 483 000 and 2.8 million days of lost productivity. Total costs ranged between A$126.5 million and A$436.7 million for asthma and between A$65.3 million and A$259.7 million for AR. Per-person annual costs ranged between A$1918 and A$6617 for asthma and between A$597 and A$2374 for AR. Conclusions The main financial burden due to asthma and AR was related to productivity losses from presenteeism and absenteeism. The magnitude of the economic impacts of AR and asthma warrants further analysis to produce a national-level assessment. Such analyses could identify cost-effective interventions that produce highest benefits for the management of these conditions in our community. What is known about the topic? Allergic respiratory diseases, and particularly asthma and AR, pose a significant health burden, with effects including asthma-related hospital admissions, significant pharmaceutical expenditure and lost workforce and school education productivity. Australia, and particularly Tasmania, has a high prevalence of these conditions, but no recent studies have appraised or estimated their health impacts and costs. What does this paper add? This paper proposes a unique and transparent costing model that allows the costs of these conditions to be estimated while accounting for restrictions in data availability. The model is used to provide the first comprehensive costings of asthma and AR in Tasmania, Australia. We identified that the estimated health costs are dominated by productivity losses from presenteeism and absenteeism, and that total per person costs are higher for a person with asthma compared to one with AR. What are the implications for practitioners? This analysis has the potential to guide cost-effective interventions by identifying where the highest benefits may be obtained when managing these conditions in our community.

Objective This paper provides an update and overview of the law governing direct-to-consumer (DTC) advertising of autologous stem cell interventions (ASCIs) in Australia. It follows significant changes to the advertising regulations made in 2018. Methods The paper reviews the three primary sources or ‘centres’ of law regulating ASCIs in Australia, together with the relevant guidance documents that supplement these sources. It provides analysis of how the post-2018 advertising regulations, contained in the Therapeutic Goods Act 1989 (Cwlth), apply to all ‘biologicals’, including ASCIs. It demonstrates how these three sources of law interact with one another and outlines the new tiered offence regime that applies to contraventions of these prohibitions. Results The analysis demonstrates that DTC advertising of ASCIs in Australia is strictly controlled, with primary legislation prohibiting the advertising of biologicals altogether. Conclusions The polycentric legal regime regulating biologicals in Australia clearly makes DTC advertising of ASCIs unlawful. Health practitioners who promote ASCIs, either online, in print or in other media forms, may be penalised in different ways and by different authorities. What is known about the topic? Although several analyses have examined the regulation of ASCIs in Australia, no analysis has studied the reforms made in 2018 relating to the advertising of biologicals. As such, this analysis contributes a fresh examination of these relatively recent reforms. What does this paper add? This analysis clarifies the effects of these new advertising regulations, providing clear guidance on the relevant legal provisions for the benefit of health practitioners and health professionals more generally. What are the implications for practitioners? Health practitioners, especially those who offer ASCIs, should be aware that civil and criminal penalties are likely to be imposed on individuals who promote biologicals in Australia by any means.

Objectives Healthcare expenditure is growing at an unsustainable rate in developed countries. A recent scoping review identified several alternative healthcare delivery models with the potential to improve health system sustainability. Our objective was to obtain input and consensus from an expert Delphi panel about which alternative models they considered most promising for increasing value in healthcare delivery in Australia and to contribute to shaping a research agenda in the field. Methods The panel first reviewed a list of 84 models obtained through the preceding scoping review and contributed additional ideas in an open round. In a subsequent scoring round, the panel rated the priority of each model in terms of its potential to improve health care sustainability in Australia. Consensus was assumed when ≥50% of the panel rated a model as (very) high priority (consensus on high priority) or as not a priority or low priority (consensus on low priority). Results Eighty-two of 149 invited participants (55%) representing all Australian states/territories and wide expertise completed round one; 71 completed round two. Consensus on high priority was achieved for 59 alternative models; 14 were rated as (very) high priority by ≥70% of the panel. Top priorities included improving medical service provision in aged care facilities, providing single-point-access multidisciplinary care for people with chronic conditions and providing tailored early discharge and hospital at home instead of in-patient care. No consensus was reached on 47 models, but no model was deemed low priority. Conclusions Input from an expert stakeholder panel identified healthcare delivery models not previously synthesised in systematic reviews that are a priority to investigate. Strong consensus exists among stakeholders regarding which models require the most urgent attention in terms of (cost-)effectiveness research. These findings contribute to shaping a research agenda on healthcare delivery models and where stakeholder engagement in Australia is likely to be high. What is known about the topic? Healthcare expenditure is growing at an unsustainable rate in high-income countries worldwide. A recent scoping review of systematic reviews identified a substantial body of evidence about the effects of a wide range of models of healthcare service delivery that can inform health system improvements. Given the large number of systematic reviews available on numerous models of care, a method for gaining consensus on the models of highest priority for implementation (where evidence demonstrates this will lead to beneficial effects and resource savings) or for further research (where evidence about effects is uncertain) in the Australian context is warranted. What does this paper add? This paper describes a method for reaching consensus on high-priority alternative models of service delivery in Australia. Stakeholders with leadership roles in health policy and government organisations, hospital and primary care networks, academic institutions and consumer advocacy organisations were asked to identify and rate alternative models based on their knowledge of the healthcare system. We reached consensus among ≥70% of stakeholders that improving medical care in residential aged care facilities, providing single-point-access multidisciplinary care for patients with a range of chronic conditions and providing early discharge and hospital at home instead of in-patient stay for people with a range of conditions are of highest priority for further investigation. What are the implications for practitioners? Decision makers seeking to optimise the efficiency and sustainability of healthcare service delivery in Australia could consider the alternative models rated as high priority by the expert stakeholder panel in this Delphi study. These models reflect the most promising alternatives for increasing value in the delivery of health care in Australia based on stakeholders’ knowledge of the health system. Although they indicate areas where stakeholder engagement is likely to be high, further research is needed to demonstrate the effectiveness and cost-effectiveness of some of these models.

Objective The study examined if, when and how select allied health professional standards currently articulate the Health LEADS Australia themes. Methods Eighteen allied health professional standards were searched to locate references to leadership. Data were extracted and analysed inductively, deductively and thematically as a meta-synthesis. Frequencies were counted, with subanalysis by professional area, classification level, competency type and level of cognition. Results There were 953 direct and indirect leadership statements. Only two leadership definitions were located, for pharmacists and dentists. The principal theme ‘Leadership’ only appeared in 18 (2%) statements from the total dataset that made direct references to leadership, which were mostly vague and unclear. The remaining indirect references to leadership are reported as four overarching themes: Self-leadership (n = 289 statements; 30%); Leadership With and of Others (n = 263; 28%); Improvement and Change Leadership (n = 223; 23%); and Health Reform Leadership (n = 139; 15%). Conclusion Health leadership was not easily recognisable in the allied health practice standards examined. With some refinement and alignment with a contemporary leadership framework, professional standards could play a critical role in preparing allied health graduates to support the ongoing health system reform required to improve health and well-being outcomes in the future. What is known about the topic? Leadership is essential at all health system levels, and leadership frameworks can usefully guide leadership development. However, little is known about allied health leadership compared with other clinical groups, and their contributions to directional changes in health system reform may be overlooked. What does this paper add? This paper presents results of an analysis of where and how 18 allied health disciplines align with the Australian Health LEADS framework, and where greater clarity or alignment is needed. What are implications for practitioners? Reinstatement of a national health leadership framework, such as the Australian Health LEADS framework, to articulate the need for and capabilities of leadership to enable innovation and support reform across all professional groups working in health care, including medical, nursing and allied health is required. A recognised national leadership framework could guide the revisions to allied health practice standards and coupled with a co-design process involving practitioners and professional associations, further development and incorporation of leadership competencies in a consistent manner would be enabled. Furthermore, alignment of allied health education and professional development with a national health leadership framework may strengthen allied health leadership graduate outcomes.

Objective Substitute decision makers (SDMs) can be required to make difficult health care decisions on behalf of individuals lacking decision-making capacity. Online resources may be helpful in preparing and supporting SDMs. This study systematically explored the frequency, content and usability of Australian online resources containing health care substitute decision-making content written for consumers. Methods In April 2019, Google searches were conducted to identify online resources containing health care substitute decision-making content for consumers. Analysis comprised mapping resource characteristics, including target audience (individual-specific, SDM-specific, mixed) and thematic analysis of content. Usability was assessed using the Patient Education Materials Assessment Tool (PEMAT). Results Of the 61 resources identified, the most frequent were webpages (57%), individual-specific (43%) and those produced by government organisations (31%). Only 15 resources (24%) were written for SDMs. Content themes identified were: defining the scope of the SDM role (93%); recommended traits or characteristics of SDMs (80%); instructions or principles regarding standards for decision making (75%); duties of SDMs (70%); and supports (46%), rights (16%), barriers (8%) and benefits (5%) for SDMs. The median (interquartile range) PEMAT scores (out of 100) were 66 (27) for understandability and 60 (55) for actionability. Conclusions SDMs have a vital role in making decisions for people lacking decision-making capacity. Online resources are a potential source of information and support for SDMs in Australia. This study identified key gaps in availability, content and usability of existing SDM resources, highlighting the need for the further development of such resources. We suggest that future resource development include SDMs in the design and evaluation processes. What is known about the topic? An aging population and a greater need for decisions to be made on behalf of others who lack capacity means that health care substitute decision-making is occurring more frequently. Appointing one or more SDMs may occur as part of the advance care planning process. However, being a healthcare SDM can be difficult and stressful. People frequently use the Internet to search for health-related information. What does this paper add? This paper systematically examined the frequency, content and usability of existing Australian online resources with substitute decision-making content written for a consumer audience in English, and identified key gaps in online resources available to support SDMs. What are the implications for practitioners? Although there is a need for resources written for SDMs, authors of online resources need to pay careful attention to the purpose, content and usability of their resource. Future resource development should include input from SDMs and involve them in evaluation to assess whether the resources meet target audience needs.

Objectives To assess whether adding clinical information and written discharge documentation variables improves prediction of paediatric 30-day same-hospital unplanned readmission compared with predictions based on administrative information alone. Methods A retrospective matched case-control study audited the medical records of patients discharged from a tertiary paediatric hospital in Western Australia (WA) between January 2010 and December 2014. A random selection of 470 patients with unplanned readmissions (out of 3330) were matched to 470 patients without readmissions based on age, sex, and principal diagnosis at the index admission. Prediction utility of three groups of variables (administrative, administrative and clinical, and administrative, clinical and written discharge documentation) were assessed using standard logistic regression and machine learning. Results Inclusion of written discharge documentation variables significantly improved prediction of readmission compared with models that used only administrative and/or clinical variables in standard logistic regression analysis (χ2 17 = 29.4, P = 0.03). Highest prediction accuracy was obtained using a gradient boosted tree model (C-statistic = 0.654), followed closely by random forest and elastic net modelling approaches. Variables highlighted as important for prediction included patients’ social history (legal custody or patient was under the care of the Department for Child Protection), languages spoken other than English, completeness of nursing admission and discharge planning documentation, and timing of issuing discharge summary. Conclusions The variables of significant social history, low English language proficiency, incomplete discharge documentation, and delay in issuing the discharge summary add value to prediction models. What is known about the topic? Despite written discharge documentation playing a critical role in the continuity of care for paediatric patients, limited research has examined its association with, and ability to predict, unplanned hospital readmissions. Machine learning approaches have been applied to various health conditions and demonstrated improved predictive accuracy. However, few published studies have used machine learning to predict paediatric readmissions. What does this paper add? This paper presents the findings of the first known study in Australia to assess and report that written discharge documentation and clinical information improves unplanned rehospitalisation prediction accuracy in a paediatric cohort compared with administrative data alone. It is also the first known published study to use machine learning for the prediction of paediatric same-hospital unplanned readmission in Australia. The results show improved predictive performance of the machine learning approach compared with standard logistic regression. What are the implications for practitioners? The identified social and written discharge documentation predictors could be translated into clinical practice through improved discharge planning and processes, to prevent paediatric 30-day all-cause same-hospital unplanned readmission. The predictors identified in this study include significant social history, low English language proficiency, incomplete discharge documentation, and delay in issuing the discharge summary.

ObjectiveThis paper presents past trends in resident characteristics and usage patterns in residential aged care and explores implications for the future. MethodsTime series analyses were undertaken of national aged care administrative datasets and the Australian Bureau of Statistics Surveys of Disability, Ageing and Carers. ResultsAlthough the number of people in residential care has continued to increase, resident profiles have changed as a result of higher growth rates in the number of men and of people aged 65–74 years and 90 years and over, and a decline in the number of women aged 75–89 years. Relative to population size, usage rates are declining across all age groups, the average length of stay is shortening, and dependency levels appear to be rising. ConclusionChanging trends in residential aged care use, when combined with key trends in the broader population of older Australians, offer useful insights in planning for the future. What is known about the topic?Trends in the changing characteristics of permanent aged care residents and patterns of use of Australian residential aged care have received sparse attention in scholarly journals. Government reports and databases contain useful statistics, but they do not provide a coherent analysis and interpretation of the implications of these trends or situate them in broader population patterns. What does this paper add?The analyses in this paper demonstrate patterns of change and continuity in the use of residential care over the past decade, and locate those changes in the context of broader trends in the ageing population. Together, this provides useful insights into current and likely future trends, as well as a basis for imagining an improved residential aged care system in the future. What are the implications for practitioners?These analyses illustrate how data on aged care services, demographic trends and disease patterns can be used to consider the challenges that have affected our residential aged care system in the past and how that may be addressed in the future.

ObjectivesThis study estimated the frequency of ultrasounds ordered for clinically obvious inguinal hernias in patients referred to surgeons and evaluated the clinical value of ultrasonography for this patient population. MethodsThe present study was a prospective diagnostic and therapeutic impact study conducted in district, rural and tertiary referral hospitals in Sydney, Hawkesbury and Wagga Wagga, Australia. The study included adult patients (≥18 years of age) who had been referred to one of the participating surgeons for an elective inguinal hernia repair. The study determined the proportion of: (1) patients who underwent an inguinal hernia repair for a clinically obvious hernia and also had an ultrasound; (2) ultrasounds ordered by general practitioners (GPs); and (3) these ultrasounds that altered diagnosis and consequent surgical management from the surgeon’s perspective. ResultsIn all, 144 participants were included in this study. Of these patients, 134 had a clinically apparent inguinal hernia on physical examination, and 63 of 133 patients (47%; 95% confidence interval (CI) 39–56%) underwent an ultrasound (information was missing for one patient). Overall 68 ultrasounds were ordered, with 63 ordered by GPs. Following the ultrasound, surgeons reported that one patient (1%; 95% CI 0–8 patients) had an altered diagnosis, and five patients (8%; 95% CI 3–17 patients) had altered management. ConclusionThis study found that almost one in two patients referred to a surgeon with a clinically obvious inguinal hernia also underwent a groin ultrasound. These studies represent an unnecessary waste of limited healthcare resources and low-value medical care because they rarely affect the final diagnosis or surgical management. What is known about the topic?Inguinal hernias are one of the most common presenting complaints to surgeons in Australia. Currently, there are no accepted Australian guidelines for the diagnosis of inguinal hernias. Ultrasound investigation has been shown to aid diagnosis when there is uncertainty after physical examination. There is increasing concern regarding low-value medical care that contributes to a significant waste of healthcare resources within Australia. The use of ultrasounds for the diagnosis of clinically apparent inguinal hernias is a potential area of concern. What does this paper add?This paper is the first to estimate the frequency of ultrasounds being ordered for clinically apparent inguinal hernias. The study shows that approximately one in two patients who present to surgeons with a clinically obvious inguinal hernia have an ultrasound. GPs were the major referral source for these ultrasounds. Finally, these ultrasounds rarely altered final diagnosis or management for patients who presented to surgeons for definitive management. What are the implications for practitioners?This study confirms that ultrasounds for clinically obvious inguinal hernias represent low-value medical care. Based on the results of this study, it is estimated that the cost to Medicare for unnecessary ultrasounds is approximately A$2.5 million per annum. Although it is beyond the scope of the present study to comment on the reasons for the apparent overinvestigation of ultrasounds for inguinal hernias, the findings suggest that clinical guidelines may help address this problem.

ObjectiveImmediate action is an emergency power available to Australian health practitioner regulatory boards to protect the public. The aim of this study was to better understand the frequency, determinants and characteristics of immediate action use in Australia. MethodsThis was a retrospective cohort study of 11200 health practitioners named in notifications to the Australian Health Practitioner Regulation Agency (AHPRA) between January 2011 and December 2013. All cases were followed until December 2016 to determine their final outcome. ResultsOf 13939 finalised notifications, 3.7% involved immediate action and 9.7% resulted in restrictive final action. Among notifications where restrictive final action was taken, 79% did not involve prior immediate action. Among notifications where immediate action was taken, 48% did not result in restrictive final action. Compared with notifications from the public, the odds of immediate action were higher for notifications lodged by employers (mandatory notifications OR=21.3, 95% CI 13.7–33.2; non-mandatory notifications OR=10.9, 95% CI 6.7–17.8) and by other health practitioners (mandatory notifications OR=11.6, 95% CI 7.6–17.8). Odds of immediate action were also higher if the notification was regulator-initiated (OR=11.6, 95% CI 7.6–17.8), lodged by an external agency such as the police (OR=11.8, 95% CI 7.7–18.1) or was a self-notification by the health practitioner themselves (OR=9.4, 95% CI 5.5–16.0). The odds of immediate action were higher for notifications about substance abuse (OR=9.9, 95% CI 6.9–14.2) and sexual misconduct (OR=5.3, 95% CI 3.5–8.3) than for notifications about communication and clinical care. ConclusionsHealth practitioner regulatory boards in Australia rarely used immediate action as a regulatory tool, but were more likely to do so in response to mandatory notifications or notifications pertaining to substance abuse or sexual misconduct. What is known about this topicHealth practitioner regulatory boards protect the public from harm and maintain quality and standards of health care. Where the perceived risk to public safety is high, boards may suspend or restrict the practice of health practitioners before an investigation has concluded. What does this paper add?This paper is the first study in Australia, and the largest internationally, to examine the frequency, characteristics and predictors of the use of immediate action by health regulatory boards. Although immediate action is rarely used, it is most commonly employed in response to mandatory notifications or notifications pertaining to substance abuse or sexual misconduct. What are the implications for practitioners?Immediate action is a vital regulatory tool. Failing to immediately sanction a health practitioner may expose the public to preventable harm, whereas imposing immediate action where allegations are unfounded can irreparably damage a health practitioner’s career. We hope that this study will assist boards to balance the interests of the public with those of health practitioners.

ObjectiveThis study assessed the effects of complementary medicines advertising policy before major changes in 2018. MethodsThe study consisted of an analysis of Complaints Resolution Panel determinations from 1999 to 2018, Therapeutic Goods Administration (TGA) post-marketing surveillance data of listed products from 2014 to 2018 and a 2018 consumer survey. ResultsOver 1999–2018, one company, Pharmacare Laboratories (with its acquisition, Cat Media), repeatedly breached the Therapeutic Goods Advertising Code at a level threefold higher than that of any other company. Determinations of the Panel were ineffective at reducing code breaches. When the Panel referred problems to the TGA, usually no action resulted. Over 2014–18, on average there were 763 breaches of the Therapeutic Goods Advertising Code per year, most commonly because claims were misleading, unverifiable or exaggerated efficacy. Over the same period, TGA post-marketing surveillance reviewed, on average, 289 listed products each year; 77% were found to be non-compliant, primarily because of an inability to substantiate the claims made. Only 15% of 684 knowledgeable consumers surveyed agreed that complementary medicines were appropriately regulated. ConclusionsNumerous complementary medicines (and medical devices) that were extensively advertised failed to meet real health needs, diverted consumers from more evidence-based treatment and wasted their money. The laws to protect consumers were adequate: the problem was lack of enforcement. What is known about the topic?The previous co-regulatory system for complementary medicines has been the subject of long-standing criticism; however, definitive data about the problems were largely unanalysed or disregarded. What does this paper add?This is the first analysis of the Complaints Resolution Panel’s determinations over its entire life (1999–June 2018). The paper provides a baseline from which the outcomes of the new complaint system (after July 2018) can be assessed. At that time, the Panel was abolished and the TGA took over the complaint system, with enhanced investigative and enforcement powers. The analysis shows that most complaints received were upheld by the Panel and a small number of sponsors repeatedly breached the Code. TGA post-marketing data from 2014 to 2018 revealed a high level of regulatory non-compliance by listed products, and a 2018 consumer survey showed low levels of trust in the regulatory system. What are the implications for practitioners?The failure of the TGA to ensure regulatory compliance by advertisers of complementary medicines (and medical devices) meant that health practitioners and consumers were unlikely to recognise the extent of misleading and deceptive claims in the marketplace. Practitioners rarely have the time or resources to investigate claims themselves. The consequence is that consumers will waste their money on useless products and be diverted from seeking more evidence-based remedies. It remains to be seen whether the new regulatory system will address these problems.

Objective To explore the perceptions of rural health professionals who use telehealth services for cardiovascular health care, including the potential role of telehealth in enhancing services for this patient group. Methods Semi-structured interviews were conducted with ten rural health professionals across a range of disciplines, including medicine, nursing and allied health. All study participants were based in the same rural region in New South Wales, Australia. Results Participant responses emphasised the importance of including rural communities in ongoing dialogue to enhance telehealth services for cardiovascular care. Divergent expectations about the purpose of telehealth and unresolved technology issues were identified as factors to be addressed. Rural health professionals highlighted the importance of all stakeholders coming together to overcome barriers and enhance telehealth services in a collaborative manner. Conclusion This study contributes to an evolving understanding of how health professionals based in regional Australia experience telehealth services. Future telehealth research should proceed in collaboration with rural communities, supported by policy that actively facilitates the meaningful inclusion of rural stakeholders in telehealth dialogue. What is known about the topic? Telehealth is frequently discussed as a potential solution to overcome aspects of rural health, such as poor outcomes and limited access to services compared with metropolitan areas. In the context of telehealth and cardiovascular disease (CVD), research that focuses on rural communities is limited, particularly regarding the experiences of these communities with telehealth. What does this paper add? This paper offers insight into how telehealth is experienced by rural health professionals. The paper highlights divergent expectations of telehealth’s purpose and unresolved technological issues as barriers to telehealth service delivery. It suggests telehealth services may be enhanced by collaborative approaches that engage multiple stakeholder groups. What are the implications for practitioners? The use and development of telehealth in rural communities requires a collaborative approach that considers the views of rural stakeholders in their specific contexts. To improve telehealth services for people living with CVD in rural communities, it is important that rural stakeholders have opportunities to engage with non-rural clinicians, telehealth developers and policy makers.

ObjectiveIdentifying and quantifying the health needs of a population are the basis of evidence-based health policy and workforce planning. The motivation for undertaking the present study was to evaluate whether the current level of medication review services corresponds to population need, as proxied by the rate of polypharmacy, and to undertake a preliminary analysis of the sufficiency of the current workforce. This paper: (1) estimates the age- and sex-standardised rates of polypharmacy as a proxy for population need for home medicines review; (2) compares the rate of polypharmacy with current service provision of home medicines reviews; and (3) links the estimated need for services with the current number and location of pharmacist providers. MethodsAge- and sex-adjusted polypharmacy rates, by state, were estimated from the National Health Survey of Australia (2017–18), service levels were estimated from national-level administrative claims data (2017–18) and the current workforce was estimated from the Australian Association of Consultant Pharmacists (2018). The current level of service provision was compared to the estimated population need for services, alongside the size of the pharmacy workforce required if need was met. ResultsThe adjusted rate of polypharmacy in Australia, using the strictest definition of ≥10 medications and ≥3 current chronic illnesses, was 1389 per 100000 population. The illustrative needs-based analysis suggests that there may be a disconnect between the current level of service provision and population health needs. ConclusionGiven that polypharmacy is a risk factor for medication-related problems, and that medication review is one of the few targeted strategies currently available to address medication-related problems in the population, service provision may be inadequate. Policy options to improve service provision could include interventions to increase workforce productivity and relaxing the current eligibility criteria for review, especially in rural and remote areas. What is known about the topic?Polypharmacy is a risk factor for medication-related problems, which can cause increased morbidity and mortality in the population. What does this paper add?This paper provides representative, population-based rates of polypharmacy in Australia and uses these rates in a needs-based analysis of service provision and workforce adequacy to provide home medicines review services. What are the implications for practitioners?Several policy options are available for consideration, including interventions to increase workforce productivity and relaxation of the current eligibility criteria for medicines review, especially in rural and remote areas.

ObjectiveDespite needs, people with advanced non-malignant respiratory disease are infrequently referred to palliative care services. Integrated models of palliative care and respiratory service delivery have been advocated to address this inequity of access. This study mapped current ambulatory palliative care service provision for patients with advanced non-malignant respiratory disease in Australia and New Zealand. MethodsAn online survey was distributed to the palliative care physician membership of the Australian and New Zealand Society of Palliative Medicine. Information was sought regarding access to specific breathlessness and integrated respiratory and palliative care services, and their operation. Data were described using descriptive statistics. ResultsIn all, 133 respondents (93 from Australia, 40 from New Zealand; representing 55 Australian and 26 New Zealand discrete sites) with complete data were available for analysis. More than half the respondents reported seeing patients with advanced non-malignant respiratory disease frequently (56/97; 58%), and 18 of 81 services (22%) reported having breathlessness or integrated respiratory and palliative care services caring for this patient group. Such services were mostly staffed by respiratory and palliative care doctors and nurses and based in the clinic environment, with limited support available outside this setting. Of the 63 respondents without existing breathlessness or integrated services, 49 (78%) expressed interest in their establishment, with limited resources cited as the most common barrier. ConclusionsThere is limited availability of integrated respiratory and palliative care or specialised breathlessness services in Australia and New Zealand despite widespread support by palliative care physicians. This study provides a snapshot to inform strategic service development. What is known about the topic?People with advanced respiratory disease have very significant morbidity with complex needs equivalent to, and in many cases more intense than, people with end-stage lung cancer; they also have significant mortality. Yet, these people frequently do not access palliative care services. The establishment of integrated respiratory and palliative care services has been advocated as an effective means to overcome the barriers to palliative care access. Such services have demonstrated improved patient and family-reported outcomes, as well as service-level improvements. What does this paper add?This paper maps the availability of integrated respiratory palliative care services in Australia and New Zealand. We reveal that although most palliative care physicians report seeing patients with advanced respiratory disease in practice, just one-fifth of services report having an integrated service approach. There was high interest and enthusiasm for such services (78%), but resources limited their establishment. What are the implications for practitioners?Palliative care services recognise the needs of patients with advanced respiratory disease and the benefits of integrated respiratory and palliative care services to address these needs, but scarcity of resources limits the ability to respond accordingly. This study provides a snapshot of current service level to inform strategic development.

ObjectiveThis study evaluated whether the satisfaction of patients attending a physiotherapy-led postarthroplasty review out-patient clinic was non-inferior to that of patients attending traditional surgeon clinics. MethodsUsing a modified nine-item Visit-Specific Satisfaction Instrument (VSQ-9), 50 patients attending the physiotherapy clinic and 50 patients attending surgeon clinics were surveyed. Sample means (±s.d.) were calculated for each domain of the VSQ-9. Non-inferiority testing was performed using 95% confidence intervals (CIs) of the adjusted mean difference to examine whether normalised patient satisfaction scores in the physiotherapy group were no worse than those in the surgeon group. ResultsBoth groups were satisfied (overall domain; 100% of both groups rated good–excellent). Based on mean item score, there was strong evidence that the satisfaction of the physiotherapy group was non-inferior to that of the surgeon group (adjusted mean difference (physiotherapy – surgeon) in mean score 5.1 (95% CI –0.3, 10.4). Furthermore, the mean differences in all but one of the nine domains were in favour of the physiotherapy group in this study. ConclusionThe satisfaction of patients attending a physiotherapy arthroplasty review clinic is not inferior to that of patients attending traditional surgeon clinics. What is known about the topic?A substitution model of care where an advanced practice physiotherapist reviews routine postarthroplasty patients instead of surgeons originated in the UK and has been adopted in Canada and Australia to address the increasingly overloaded public out-patient health services. Evidence of clinical and cost effectiveness has been demonstrated but, to the best of the authors’ knowledge, only one paper has evaluated consumer engagement, and that paper was in a Canadian population. What does this paper add?This study evaluated the satisfaction of patients in an Australian public healthcare system and was able to demonstrate that patients seen by physiotherapists were no less satisfied than those seen by surgeons in traditional clinics. The findings support those reported in the Canadian study. This is an important step in the development and acceptance of these substitution model of care innovations locally. What are the implications for practitioners?The results of this study will provide an important addition to the evidence of the clinical efficacy of this model of care: that of consumer acceptance. This will assist with planning, expansion and rollout of similar initiatives in Australia.

ObjectiveConsumer and community engagement (CCE) in research is increasingly valued in a contemporary healthcare environment that seeks to genuinely partner with consumers and the wider community. Although there is widespread agreement at research governance levels as to the benefits of CCE in research, there is little available research-based guidance as to how best to proceed with CCE organisationally and how to manage and overcome barriers. The aim of this narrative review was to draw together the available research, review findings and relevant governance-related material and to discuss these in light of a case series among research-engaged consumers in order to chart a practical way forward. MethodsA narrative literature review about CCE in research was conducted. Following this, a case series among seven consumers who had been engaged as partners in health research was conducted. Finally, the lived experience of these consumers was explored against the findings of the narrative review. ResultsIn all, 121 papers were identified and reviewed, 37 of which were used to inform the content of this paper. The most important benefits of CCE to both consumers and healthcare researchers were related to improvements in trust between consumer and researchers, and the increased relevance and ethics of research agendas ultimately pursued. Barriers to CCE were found to be pragmatic, attitudinal and organisational. Enabling factors that capitalise on the benefits and help address the barriers to meaningful CCE are outlined and discussed in light of a case series conducted among research-engaged consumers in Australia and internationally. ConclusionBest practice standards, organisational commitments and resources are needed to improve the status quo in Australia and to provide health research end-users with research outcomes that better align with their priorities and needs. What is known about the topic?Consumer and community engagement (CCE) in research is increasing in prevalence and is likely to be beneficial to both consumers and healthcare providers and researchers. What does this paper add?Following review of the available research findings and governance statements about CCE, enabling strategies are presented in light of a case series among Sydney-based research-engaged consumers. What are the implications for practitioners?Barriers to consumer and community engagement can be overcome if well understood and tackled organisationally. The potential benefits of shifting to a fully consumer- or community-engaged healthcare research environment are multifactorial and represent a paradigm shift in favour of evidence-based patient and family-centred care.

Objective The aim of this study was to understand, from the perspective of policy makers, who holds the responsibility for driving evidence-based policy to reduce the high burden of cardiovascular disease (CVD) in rural Australia. Methods Qualitative interviews were conducted with policy makers at the local, state and federal government levels in Australia (n = 21). Analysis was conducted using the Conceptual Framework for Understanding Rural and Remote Health to understand perceptions of policy makers around who holds the key responsibility in driving evidence-based policy. Results At all levels of government, there were multiple examples of disconnect in the understanding of who is responsible for driving the generation of evidence-based policy to reduce CVD in rural areas. Policy makers suggested that the rural communities themselves, health services, health professionals, researchers and the health sector as a whole hold large responsibilities in driving evidence-based policy to address CVD in rural areas. Within government, there was also a noticeable disconnect, with local participants feeling it was the federal government that held this responsibility; however, federal government participants suggested this was largely a local government issue. Overall, there seemed to be a lack of responsibility for CVD policy, which is reflected in a lack of action in rural areas. Conclusion There was a lack of clarity about who is responsible for driving evidence-based policy generation to address the high burden of CVD in Australia, providing one possible explanation for the lack of policy action. Clarity among policy makers over shared roles and leadership for policy making must be addressed to overcome the current burden of CVD in rural communities. What is known about the topic? Rural health inequalities, such as the increased burden of CVD in rural Australia are persistent. Such health inequalities are unjust, with global theory suggesting political processes have facilitated, in part, the inequalities. With similar examples observed internationally in rural areas, little is known about the influence of the perspectives of policy makers regarding who is responsible for addressing health issues in rural areas, in the government context. What does this paper add? This paper provides empirical evidence, for all levels of government in Australia, that there is a lack of clarity in policy roles and responsibilities to address the unequal burden of CVD in rural Australia, at all levels of government. The paper provides evidence to support the urgent need for clarity within government around policy stakeholder roles. Without such clarity, it is unlikely that national-level progress in addressing rural health inequalities will be achieved in the near future. What are the implications for practitioners? Addressing ambiguity around who is responsible for the development of evidence-based policy to address the high burden of CVD in rural areas must be a high priority to ensure health disparities do not persist for future Australian generations. The results reported here are highly relevant to the Australian context, but also reflect similar findings internationally, namely that a lack of clarity among policy stakeholders appears to contribute to reduced action in addressing preventable health inequalities in disadvantaged populations. This paper provides evidence for policy makers and public health professionals to advocate for clear policy roles and direction in rural Australia.

ObjectiveThis study investigated the delivery of guideline-recommended services for the management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Australian primary healthcare centres participating in the Audit and Best Practice for Chronic Disease (ABCD) National Research Partnership project. MethodsARF and RHD clinical audit data were collected from 63 Aboriginal centres in four Australian jurisdictions using the ABCD ARF/RHD audit tool. Records of up to 30 patients treated for ARF and/or RHD were analysed per centre from the most recent audit conducted between 2009 and 2014. The main outcome measure was a quality of ARF and RHD care composite indicator consisting of nine best-practice service items. ResultsOf 1081 patients, most were Indigenous (96%), female (61%), from the Northern Territory and Queensland (97%) and 15 years to be a significant negative factor for several care indicators, particularly for the delivery of long-acting antibiotic injections and specialist services in the 15–24 year age group. ConclusionsThe results suggest that timely injection and patient education are priorities for managing ARF and RHD, particularly focusing on child-to-adult transition care. What is known about the topic?The burden of rheumatic fever and RHD in some Aboriginal communities is among the highest documented globally. Guideline-adherent RHD prevention and management in primary health care (PHC) settings are critically important to reduce this burden. Continuous quality improvement (CQI) is a proven strategy to improve guideline adherence, using audit cycles and proactive engagement of PHC end users with their own data. Previously, such CQI strategies using a systems approach were shown to improve delivery of ARF and RHD care in six Aboriginal health services (three government and three community controlled). What does this paper add?This paper focuses on the variation across age groups in the quality of ARF and/or RHD care according to nine quality of care indicators across 63 PHC centres serving the Aboriginal population in the Northern Territory, Queensland, South Australia and Western Australia. These new findings provide insight into difference in quality of care by life stage, indicating particular areas for improvement of the management of ARF and RHD at the PHC level, and can act as a baseline for monitoring of care quality for ARF and RHD into the future. What are the implications for practitioners?Management plans and innovative strategies or systems for improving adherence need to be developed as a matter of urgency. PHC professionals need to closely monitor adherence to secondary prophylaxis at both the clinic and individual level. RHD priority status needs to be assigned and recorded as a tool to guide management. Systems strengthening needs to particularly target child-to-adult transition care. Practitioners are urged to keep a quick link to the RHDAustralia website to access resources and guidelines pertaining to ARF and RHD (https://www.rhdaustralia.org.au/arf-rhd-guideline, accessed 3 October 2019). CQI strategies can assist PHC centres to improve the care they provide to patients.

Objective The first objective of this study was to assess the associations between individual, community and hospital factors with emotional exhaustion (EE) among rural Australian doctors in training (DITs); the second objective was to apply criteria from an international standard that measures sustainable employability in organisations. Methods A cross-sectional study of 70 DITs was conducted. Odds ratios (ORs) with 95% confidence intervals (CIs) of EE across individual, community and organisational factors were calculated. Results DITs with poor or moderate ability to cope with mental work demands had higher odds of being emotionally exhausted (OR 8.273; 95% CI 1.693–40.423), as did DITs with sleep disturbance (OR 6.187; 95% CI 1.721–22.242). Higher psychological distress (OR 1.701; 95% CI 1.286–2.249), more hours worked on-call (OR 1.052; 95% CI 1.011–1.094) and increased presenteeism (OR 1.285; 95% CI 1.049–1.576) were associated with being emotionally exhausted. Those who felt ambivalent or unsatisfied with hospital support networks had threefold higher odds of EE (OR 3.323; 95%CI 1.191–9.273). All metrics associated with the International Organisation for Standardisation (ISO) sustainable employability guidelines were significantly associated with EE; DITs who thought the hospital did not promote physical (OR 5.489; 95%CI 1.494–20.162) or mental health behaviours (OR 4.750; 95%CI 1.228–18.406) and those who did not perceive DITs overall well-being to be prioritised had higher odds of EE (OR 8.800; 95% CI 1.920–40.336). Conclusions When DITs perceive the hospital promotes and prioritises well-being measures and provides a supportive environment, they are less likely to experience EE. This pilot study demonstrated the value of using an international standard to measure sustainable employability in hospitals. What is known about the topic? Doctors are an at-risk population with increased rates of suicide, depression and anxiety compared with other professions. Junior doctors and regional DITs experience a greater burden of psychological distress, burnout and compassion fatigue than non-training, urban-based doctors. Regional and rural communities are often characterised by fewer doctors per head of population and workforce shortage, with an identified need to optimise the mental well-being of rural doctors to retain the medical workforce and ensure they continue to meet the needs of these rural communities. What does this paper add? This paper adds to the evidence about the well-being of regional DITs. This pilot study is unique in its demonstration of the relationship between EE and sustainable employability factors within hospitals. The use of an international standard to measure elements of sustainable employability at the organisational level in relation to well-being can potentially be further tested and replicated across the whole organisation and in other healthcare organisations and professions. What are the implications for practitioners? Rural hospital administrators and policy makers can potentially use the results to guide hospital interventions aimed at alleviating EE in DITs. It appears that supportive hospital environments are key factors to consider when developing these interventions. The international standard guidelines on sustainable employability can be used by top management and human resource managers to develop sustainable employability metrics.

ObjectiveMen who experience homelessness in Australia often have complex health and social issues, including the trimorbidity of concurrent mental illness, substance use disorders and physical health conditions. These men tend to have poor health outcomes, and present challenges to healthcare systems. To improve system responsiveness and patient outcomes, the perspectives of marginalised groups need to be understood. MethodsFive focus groups were conducted with 20 men in a homeless men’s hostel, exploring their experiences of seeking and receiving health care, and views about improving these. An inductive thematic analysis was undertaken. ResultsSeveral participants expressed gratitude for care provided for life-threatening physical illness and trauma. However, negative experiences of health system responses were more frequently reported. Four emerging themes all made securing effective ‘tickets of entry’ to health care more difficult: dismissive care, care fragmentation, inconsistent medical management of pain and inadequate acknowledgement of psychological distress. ConclusionsImprovements are needed in care integration and the de-escalation of potentially confrontational interactions. Effective, safe and compassionate system responses to presentations of psychological distress and pain should be collaboratively developed. Some current responses may entrench stigma, further traumatising vulnerable patients. What is known about the topic?Men who experience homelessness have poor health outcomes and present challenges to healthcare systems. What does this paper add?This paper describes healthcare experiences and insights of men who are experiencing homelessness in Australia. These men reported experiencing dismissive care, care fragmentation, inconsistent, inadequate and/or unsafe prescribing for pain and inconsistent and/or ineffective responses to psychological distress. What are the implications for practitioners?Changes are needed in health system responses, informed by the experiences and insights of marginalised people, to break cycles of trauma and exclusion.

Digital transformation of Australian hospitals is occurring rapidly. Although the clinical community has had limited ability to influence high-level decision making and investments into digital health technologies, as these technologies increasingly transform the way patients are cared for, the clinical community must influence the digital health agenda and be an integral part of the decision-making process. This case study details the process and lessons learnt during the development of the state-wide consensus statement detailing the clinical requirements for digital health initiatives to form the Queensland Digital Health Clinical Charter. To the best of our knowledge, Queensland is the first Australian jurisdiction to create a Digital Clinical Charter to be specifically referenced in the investment in and governance of digital health in hospitals. By developing this clinical charter for digital health, and in articulating the needs of clinicians, a clinical framework will be added to both the decision-making process around the investments in digital health and the definition and realisation of the expected benefits from these sizable investments. What is known about the topic? Digital transformation of healthcare is occurring rapidly. The clinical community has had limited ability to influence high-level decision making and investments into these digital health technologies. Tension currently exists between the clinical community who must use the new digital technologies and the technical groups that govern the introduction of the new technologies. This tension can be manifest as clinicians refusing to adopt new systems, safety concerns and an inability to reach consensus on direction. There are few peer reviewed publications addressing this tension between the clinical community and technical providers. What does this paper add? This paper is the first attempt to create a list of clinical requirements for digital transformation that crosses professional streams and is endorsed by the state-wide executive leadership team to inform the acquisition and governance of digital health technologies. What are the implications for practitioners? Clinicians can feel excluded and marginalised during the decision-making process for new digital technologies, despite the fact that they are often using these technologies to deliver hands-on care to patients. This charter clearly articulates the requirements of clinicians for digital transformation and has been endorsed by the executive leadership team of Queensland Health. The charter adds a clinical framework to be referenced during the decision-making process around the investments in digital health, and the definition and realisation of the expected benefits from these sizable investments. As the digital landscape in public hospitals evolves, clinicians are becoming increasingly reliant upon digital technologies. It is critical that clinicians have a strong effect on technology acquisition and governance to maximise the quality and efficiency of the care they provide.

ObjectiveThis retrospective study identified and compared the performance of electronic discharge summaries (EDSs) from three hospital in-patient streams (surgical, medical and mental health) with Australian standards. MethodsAn audit was performed of 120 EDSs extracted from a tertiary hospital. Auditors evaluated each EDS using an adaptation of the Australian Commission on Safety and Quality in Health Care’s EDS toolkit. ResultsEDSs from all in-patient streams were lengthy and most did not include information regarding discharge destination, patient education or recommendations. General Medicine EDSs were most timely, averaging within 1 day of discharge. ConclusionsKey areas of improvement remain for improving the timeliness, brevity and completeness of EDSs. Key areas identified for improvement include page length, discharge destination, alerts, patient education and recommendations. Variability in audit results between streams suggests the need for speciality-specific templates, standards and medical officer training. What is known about the topic?The literature suggests that an EDS is timely if it is completed within 2 days of discharge. A complete and brief EDS should also include key details of the care in two (or fewer) pages. What does this paper add?This paper evaluated 120 EDSs, compared them against a standard and stratified the EDSs according to three core clinical in-patient streams that produced them (surgical, medical and mental health). What are the implications for practitioners?Although broad guidelines for timeliness, brevity and completeness have been established for EDSs, each in-patient stream will require different standards. A hospital or health service should have established standards relevant to each in-patient stream. Before commencing a term in any of the three in-patient streams, medical officers who are to generate EDSs should be trained in the required standard. Training should highlight critical elements of a speciality stream to ensure EDS authors are aware of the nuances of the stream in which they are rotating. In addition, general practitioners should liaise with local hospitals to ensure ongoing dialogue and improvement of clinical handover documents.

Objective This review systematically identified studies that estimated the prevalence of prescription opioid use in Australia, assessed the prevalence estimates for bias and identified areas for future research. Methods Literature published after 2000 containing a potentially representative estimate of prescription opioid use in adults, in the community setting, in Australia was included in this review. Studies that solely assessed opioid replacement, illicit opioid usage or acute hospital in-patient use were excluded. Databases searched included PubMed, EMBASE, Web of Science and the grey literature. Results The search identified 2253 peer-reviewed publications, with 34 requiring full-text review. Of these, 20 were included in the final qualitative analysis, in addition to four publications from the grey literature. Most studies included analysed prescription claims data for medicines dispensed via Australia’s national medicines subsidy scheme (the Pharmaceutical Benefits Scheme). Although data sources were good quality, all prevalence estimates were at least at moderate risk of bias, predominantly due to incompleteness of data or potential confounding. Included publications demonstrated a significant rise in opioid use up to 2017 (including a 15-fold increase in prescriptions dispensed over the 20 years to 2015), predominantly driven by a sharp rise in oxycodone use. Although opioid prescription numbers continue to escalate, usage, as measured by oral morphine equivalent per capita, may have plateaued since 2014. Codeine remains the most prevalently obtained opioid, followed by oxycodone and tramadol. There was a substantial delay (median 30 months; interquartile range 20–37 months) to publication of opioid usage data from time of availability. Conclusions Australia has experienced a marked increase in opioid prescribing since the 1990s. Current published literature is restricted to incomplete, delayed and historical data, limiting the ability of clinicians and policy makers to intervene appropriately. What is known about the topic? Opioid prescriptions in Australia have continued to increase since the 1990s and may be mirroring the epidemic being seen in the US. What does this paper add? This paper systematically identifies all publications that have examined the prevalence of prescription opioid use in Australia since 2000, and only identified prevalence estimates that were at moderate or high risk of bias, and found significant delays to publication of these estimates. What are the implications for practitioners? Because published literature on the prevalence of prescription opioid consumption is restricted to incomplete, delayed and historical data, the ability of clinicians and policy makers to appropriately intervene to curb prescription opioid use is limited. A national policy of real-time monitoring and reporting of opioid prescribing may support improvements in practice.

Objectives The poor oral health of Australians experiencing homelessness negatively affects their quality of life. Better oral health is associated with having annual dental check-ups. Because there is limited peer-reviewed literature describing strategies that improve access to and uptake of dental care by homeless people, in this study we searched the grey literature to discover what strategies are used. Methods The Informit database and Google and Bing search engines were searched using the keywords ‘homeless and oral and dental services’. Bing and Google were searched unrestricted by site and Google was searched for sites ending in ‘org.au’. Searches were restricted to Australia from June 2008 to June 2018. The first 300 websites were read, and those describing or linking to pages describing a strategy that improved access to or uptake of dental care were included in the study. The content of the webpages was evaluated and summarised, with common strategies reported as a narrative description. Results Nineteen programs were described. Common strategies were providing free care, in-reach care, outreach care and the need to work closely with support organisations. Conclusions To improve access to and uptake of dental care by people experiencing homelessness, dental services need to be free and organised in collaboration with support organisations. What is known about the topic? The peer-reviewed literature describing strategies used to improve access to and uptake of dental care by people experiencing homelessness in Australia is limited. The authors could only locate two such studies, one based in Melbourne and one in Brisbane. Both programs had a similar aim, but used different strategies to achieve it, suggesting a lack of consensus about the best way to encourage dental visiting by people experiencing homelessness. What does this paper add? This paper used the grey literature to describe common strategies used in Australia to improve access to and uptake of dental care by people experiencing homelessness. What are the implications for practitioners? Dental service providers aiming to increase access to and uptake of dental care by people experiencing homelessness need to work collaboratively with support organisations and provide care free of charge.

The Australian Commission for Safety and Quality in Health Care has created the National Safety and Quality Health Service standards that all hospitals must address in order to remain accredited. This case study details the first known digitisation of the 10 national quality and safety standards mandated in a quaternary integrated digital hospital. A team of clinical informaticians, information technology experts and clinicians was assembled. Data were chosen and the data were then extracted and validated and presented (often in near real time) in an easily consumable dashboard format with appropriate governance to allow clinicians and executives to monitor the quality and safety standards across the hospital. All 10 standards were defined and extracted contemporaneously from the digital hospital for every patient, every time. This is in stark contrast with traditional retrospective point prevalence surveys. This case study details the first known fully digital accreditation in a sophisticated integrated digital hospital. Digitisation of hospital quality and safety to produce real-time data is the future of clinical redesign to improve patient care. What is known about the topic? Healthcare delivery is complex and the ability of healthcare providers to maintain consistent standards of quality and safety is variable. Traditionally, these standards have been assessed by intermittent retrospective point-prevalence survey activity. Sophisticated digital hospitals provide the opportunity to develop data and analytics that monitor quality and safety standards across every patient, every time in near real time. What does this paper add? This paper describes a digital hospital which has created streaming analytics to monitor live performance of quality and safety standards. The necessary skills, leadership and governance for this process are outlined and the products described. What are the implications for practitioners? Shifting from retrospective paper-based point prevalence surveys to a digital platform has several implications. Firstly, it is an imperative to drive digital transformation of Australian hospitals. Secondly, it provides data for intervention to the hospital staff, so that issues can be addressed and improved in real-time, rather than waiting for survey results. Lastly, this new model of maintaining quality and safety also requires the development of new skills in the hospital setting including data literacy, digital clinical governance and clinical informatics.

Objective To describe the implementation of a model of integrated care for chronic disease in Western Sydney. This model was established on the basis of a partnership between the Local Health District and the Primary Health Network. Methods The Western Sydney Integrated Care Program (WSICP) focuses on people with type 2 diabetes, chronic obstructive pulmonary disease and coronary artery disease or congestive cardiac failure. We describe the design of the program, the processes involved and some of the challenges and barriers to integration. Results Early data indicate a high uptake of services, with some evidence of a reduction in hospital admissions and presentations to the emergency department. Conclusion A model of integrated care has been successfully implemented and embedded into local practices. Preliminary data suggest that this is having an impact on the utilisation of hospital services. What is known about the topic? There is evidence that integrated models can improve cost-effectiveness and the quality of clinical care for people with chronic disease. However, most integrated models are small scale, focus on very specific populations and generally do not engage both primary care and acute hospitals. What does this paper add? This paper describes an effective partnership between state-funded hospital services in the WSLHD and the federally funded local Primary Health Network (PHN) of general practitioners. The paper outlines the design of the program and the structural, governance and clinical steps taken to embed integrated care into everyday clinical practice. In addition, preliminary results indicate a reduction in the use of hospital services by people who have received integrated care services. What are the implications for practitioners? Involvement of both primary care and the public hospital system is important for a successful and sustainable integrated care program. This is a long and challenging process, but it can lead to positive effects not just for individuals, but also for the health system as a whole.

The advertising of regulated health services to consumers is strictly regulated in Australia. The advertising prohibitions within the National Law that ban the use of testimonials relating to services provided by health practitioners have caused controversy, garnering mixed reactions from the health professions, health consumers and other stakeholders. Advertising that misleads health consumers may promote unnecessary and inappropriate engagement in health services and may therefore negatively affect consumers’ ability to exercise autonomous decisions relating to their care. This article considers policy implications relating to advertising with a focus on the use of testimonials, particularly those that are online. Although there would seem to be appetite for amending the current legislative framework, there is uncertainty as to the form change may take and the effect this could have. What is known about the topic? Testimonials relating to health care are a prohibited form of advertising, but a form still used by non-regulated health providers and those who are regulated but who are either ignorant of the law or defiant of its requirements. Views are split as to whether the restriction on consumer reviews of regulated health services is reasonable; frequently, arguments are put forward stating that the status quo inhibits consumers’ ability to discuss their care. Other jurisdictions outside Australia permit the use of patient reviews and testimonials. What does this paper add? This paper discusses the greater policy implications of the current restrictions within the National Law and analyses the arguments placed forward by different stakeholders from the health professions and those that consume health services. The ethical and market arguments surrounding advertising and testimonials are examined. Suggestions are then made as to the deficits in knowledge that presently exist relating to this area and the actions required before future policy may be developed. What are the implications for practitioners? Practitioners should be aware of the current restrictions upon advertising within regulated health services. This paper develops an understanding of the complex arguments surrounding advertising and testimonials in health care, as well as when testimonials may be permitted and not subject to the current regulations. Before any amendment to the current legislation is actioned, regulators should consider instead the need to develop an evidence-based approach to understanding the effects of health advertising on the decision making of healthcare consumers.

Objective Analytical techniques are being implemented with increasing frequency to improve the management of surgical departments and to ensure that decisions are well informed. Often these analytical techniques rely on the validity of underlying statistical assumptions, including those around choice of distribution when modelling uncertainty. The aim of the present study was to determine a set of suitable statistical distributions and provide recommendations to assist hospital planning staff, based on three full years of historical data. Methods Statistical analysis was performed to determine the most appropriate distributions and models in a variety of surgical contexts. Data from 2013 to 2015 were collected from the surgical department at a large Australian public hospital. Results A log-normal distribution approximation of the total duration of surgeries in an operating room is appropriate when considering probability of overtime. Surgical requests can be modelled as a Poisson process with rate dependent on urgency and day of the week. Individual cancellations could be modelled as Bernoulli trials, with the probability of patient-, staff- and resource-based cancellations provided herein. Conclusions The analysis presented herein can be used to ensure that assumptions surrounding planning and scheduling in the surgical department are valid. Understanding the stochasticity in the surgical department may result in the implementation of more realistic decision models. What is known about the topic? Many surgical departments rely on crude estimates and general intuition to predict surgical duration, surgical requests (both elective and non-elective) and cancellations. What does this paper add? This paper describes how statistical analysis can be performed to validate common assumptions surrounding surgical uncertainty. The paper also provides a set of recommended distributions and associated parameters that can be used to model uncertainty in a large public hospital’s surgical department. What are the implications for practitioners? The insights on surgical uncertainty provided here will prove valuable for administrative staff who want to incorporate uncertainty in their surgical planning and scheduling decisions.

The purpose of this paper is to clarify the relationship between medical practitioners (MPs) and nurse practitioners (NPs) in general, and privately practising NPs (PPNPs) in particular, in relation to collaboration, control and supervision in Australia, as well as to explore the difficulties reported by PPNPs in establishing mandated collaborative arrangements with MPs in Australia. In order for the PPNPs to have access to the Medicare Benefit Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) in Australia, they are required, by law, to establish a collaborative arrangement with an MP or an entity that employs MPs. This paper begins by describing the history of and requirements for collaborative arrangements, then outlines the nature of successful collaboration and the reported difficulties. It goes on to address some of the commonly held misconceptions in order to allay medical concerns and enable less restrictive access to the MBS and PBS for PPNPs. This, in turn, would improve patient access to highly specialised and expert PPNP care. What is known about the topic? NPs have been part of the Australian health workforce since 1998, but until 2009 their patients did not receive any reimbursement for care delivered by PPNPs. In 2009, the Federal government introduced limited access for PPNPs to the MBS and PBS, but only if they entered into a collaborative arrangement with either an MP or an entity that employs MPs. What does this paper add? The introduction of collaborative arrangements between PPNPs and MPs seems, in some instances, to have created confusion and misunderstanding about the way in which these collaborative arrangements are to operate. This paper provides clarification of the relationship between MPs and NPs in general, and PPNPs in particular, in relation to collaboration, control and supervision. What are the implications for practitioners? A clearer understanding of these issues will hopefully enable greater collegial generosity and improve access to patient care through innovative models of service delivery using NPs and PPNPs.

Objective The aim of this study was to describe the experiences of communication for staff providing cardiac care for Aboriginal and Torres Strait Islander patients in hospital and discuss potential improvements. Methods Focus group discussions were performed with 58 multidisciplinary staff who provide care for Aboriginal and Torres Strait Islander cardiac patients in two metropolitan and two regional hospitals in South Australia and Northern Territory. Inductive thematic analysis was undertaken to identify staff perceptions of communication challenges and strategies for improvement. Results There were five key themes: (1) communication is central to good care; (2) communication within busy clinical environments; (3) supporting a strong Aboriginal workforce; (4) a cultural as well as clinical focus; and (5) particular challenges working with patients from remote areas. Conclusions Providing effective communication that is both clinically and culturally appropriate is often challenging within a busy and non-adaptive hospital environment. Moving beyond clinical tasks, increased Aboriginal and Torres Strat Islander health workforce and cultural competency, supporting coordinated care and improved skills are required to meet the communication needs of Aboriginal and Torres Strait Islander patients. What is known about this topic? Communication between patients, their families and hospital staff is crucial for health care quality and safety. There is little understanding of the challenges and opportunities for staff to meet the communication needs of Aboriginal and Torres Strait Islander cardiac patients to address disparities in acute care settings. What does this paper add? This paper discusses the barriers and potential improvements, as identified by hospital staff providing care to Aboriginal and Torres Strait Islander cardiac patients in both metropolitan and regional settings. What are the implications for practitioners? Practitioners should be trained and supported in providing both clinically and culturally safe care for Aboriginal and Torres Strait Islander patients. This requires adequate time, two-way communication and resources to support and facilitate effective communication.

Learning from medical errors to prevent their recurrence is an important component of any healthcare system’s quality and safety improvement functions. Traditionally, this been achieved principally from review of adverse clinical outcomes. The opportunity to learn systematically and in a system manner from patient complaints and litigation has been less well harnessed. Herein we describe the pathways and processes for both patient complaints and medicolegal claims in Victoria, and Australia more broadly, and assess the potential for these to be used for system improvement. We conclude that both patient complaints and medicolegal claims could afford the potential to additionally inform and direct safety and quality improvement. At present neither patient complaints nor medicolegal claims are used systematically to improve patient safety. We identify how this may be done, particularly through sharing findings across agencies. What is known about the topic? Patient complaints and medicolegal claims are accepted parts of the healthcare industry. However, using these in a shared and collated manner as part of an improvement agenda has not been widely considered or proposed. What does the paper add? This paper provides a summary of the patient complaint and medicolegal landscape in public hospital system in Australia broadly, and Victoria more specifically, identifying the agencies involved and the opportunities for sharing learnings. The paper draws on existing literature and experiences from both Australia and elsewhere to propose a framework whereby complaints and claims data could be shared systematically and strategically to reduce future harm and improve patient care. What are the implications for practitioners? We offer an approach for practitioners, healthcare managers and policy makers in all Australian jurisdictions to design and implement a statewide capacity to share patient complaints and medicolegal claims as an additional component of system quality and safety.

Objective The aim of this study is to describe the experience of developing key performance indicators (KPIs) for Sydney Children’s Hospital Network (SCHN), the largest paediatric healthcare entity in Australia. Methods Beginning with a published methodology, the process of developing KPIs involved five phases: (1) identification of potential KPIs referencing the organisational strategic plan and pre-existing internal and external documents; (2) consolidation into a pragmatic set; (3) analysis of potential KPIs against selection criteria; (4) mapping these back against the strategic plan and management structure; and (5) presentation to key stakeholders to ensure suitability and traction. Consistent with the strategic plan, a subset of indicators was selected to address quality of care for children from priority populations. Results A pragmatic list of 60 mandated and 50 potential KPIs was created from the 328 new and 397 existing potentially relevant KPIs generated by the executive team. Of these, 20 KPIs were selected as the most important; 65% were process measures. The majority of mandated KPIs were process measures. Of the KPIs selected to highlight inequities, there were proportionately more outcome measures (44% outcome, 27% process). Less than one-third could currently be measured by the organisation and were thus aspirational. Conclusion Developing a KPI suite requires substantial time, effort and organisational courage. A structured approach to performance measurement and improvement is needed to ensure a balanced suite of KPIs that can be expected to drive an organisation to improve child health outcomes. Future directions for SCHN include a systematic approach to implementation beyond the mandated KPIs, including KPIs that reflect equity and improved outcomes for priority populations, development of meaningful measures for the aspirational KPIs, adding structure KPIs and measurement of changes in child health outcomes related to the development of this KPI process. What is known about the topic? Health services are increasingly required to demonstrate accountability through KPIs. There is a body of literature on both theoretical frameworks for measuring performance and a long list of possible measures, however developing a meaningful suite of KPIs remains a significant challenge for individual organisations. What does this paper add? This paper describes lessons learned from the practical, pragmatic application of a published methodology to develop a suite of KPIs for the largest paediatric healthcare entity in Australia. It provides a select list of the highest-level KPIs selected by the organisation to stimulate further discussion among similar organisations in relation to KPI selection and implementation. What are the implications for practitioners? Developing and implementing a suite of meaningful KPIs for a large organisation requires courage, an understanding of health informatics, stakeholder engagement, stamina and pragmatism. The process we describe can be replicated and/or modified as needed, with discussion of key lessons learned to help practitioners plan ahead.

Objective A growing body of research indicates that paramedics may have a greater role to play in health care service provision, beyond the traditional models of emergency health care. The aim of this study was to identify and synthesise the literature pertaining to the role of paramedic-initiated health education within Australia, with specific consideration of metropolitan, rural and remote contexts. Methods A literature review was undertaken using the Ovid Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE and Scopus databases. The search time frame was limited from January 2007 to November 2017. The search was performed using key paramedic search terms in combination with keywords such as health education, rural, metropolitan, remote and Australia. Reference lists from relevant papers were also reviewed. Results Fourteen articles met the inclusion criteria for synthesis. Health education in the Australian paramedic context relates largely to expanded-scope paramedics, health promotion and the role of paramedics as key members of local communities. There were no studies specifically related to the paramedic role in health education, although many papers referred to health education as one of many roles paramedics engage in today. Conclusion This review highlights a broadening of paramedicine’s traditional scope of practice, and an indication of how vital paramedics could be to local communities, particularly in rural and remote areas. An expanded role may help address health workforce sustainability problems in areas where health care provision is challenged by geographical constraints and low workforce numbers. What is known about the topic? A broadening of paramedicine’s traditional scope of practice has been linked to improvements in health workforce sustainability problems in areas where health care provision is challenged by geographical constraints and low workforce numbers, such as rural and remote Australia. Health education, as well as health promotion, primary health care and chronic disease management, have been proposed as potential activities that paramedics could be well placed to participate in, contributing to the health and well-being of local communities. What does this paper add? This paper identifies and synthesises literature focusing on paramedic-initiated health education in the Australian context, assessing the current health education role of paramedics in metropolitan, rural and remote areas. It provides an understanding of different geographical areas that may benefit from expanded-scope prehospital practice, indicating that the involvement of paramedics in health education in Australia is significantly determined by their geographical place of work, reflecting the influence of the availability of healthcare resources on individual communities. What are the implications for practitioners? Today’s paramedics fill broader roles than those encompassed within traditional models of prehospital care. Rural and remote communities facing increasing difficulty in obtaining health service provision appear to benefit strongly from the presence of expanded-scope paramedics trained in health promotion, primary injury prevention, chronic disease management and health education: this should be a consideration for medical and allied health practitioners in these areas. Australian paramedics are uniquely placed to ‘fill the gaps’ left by shortages of healthcare professionals in rural and remote areas of the country.

International datasets from general practice enable the comparison of how conditions are managed within consultations in different primary healthcare settings. The Australian Bettering the Evaluation and Care of Health (BEACH) and TransHIS from the Netherlands collect in-consultation general practice data that have been used extensively to inform local policy and practice. Obesity is a global health issue with different countries applying varying approaches to management. The objective of the present paper is to compare the primary care management of obesity in Australia and the Netherlands using data collected from consultations. Despite the different prevalence in obesity in the two countries, the number of patients per 1000 patient-years seen with obesity is similar. Patients in Australia with obesity are referred to allied health practitioners more often than Dutch patients. Without quality general practice data, primary care researchers will not have data about the management of conditions within consultations. We use obesity to highlight the strengths of these general practice data sources and to compare their differences. What is known about the topic? Australia had one of the longest-running consecutive datasets about general practice activity in the world, but it has recently lost government funding. The Netherlands has a longitudinal general practice dataset of information collected within consultations since 1985. What does this paper add? We discuss the benefits of general practice-collected data in two countries. Using obesity as a case example, we compare management in general practice between Australia and the Netherlands. This type of analysis should start all international collaborations of primary care management of any health condition. Having a national general practice dataset allows international comparisons of the management of conditions with primary care. Without a current, quality general practice dataset, primary care researchers will not be able to partake in these kinds of comparison studies. What are the implications for practitioners? Australian primary care researchers and clinicians will be at a disadvantage in any international collaboration if they are unable to accurately describe current general practice management. The Netherlands has developed an impressive dataset that requires within-consultation data collection. These datasets allow for person-centred, symptom-specific, longitudinal understanding of general practice management. The possibilities for the quasi-experimental questions that can be answered with such a dataset are limitless. It is only with the ability to answer clinically driven questions that are relevant to primary care that the clinical care of patients can be measured, developed and improved.

Objective The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Methods Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. Results There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were ‘human factors’ and ‘unfamiliarity or training’ (70%) and ‘cross-encounter or hybrid system errors’ (22%). Conclusions Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. What is known about the topic? eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. What does this paper add? This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. What are the implications for practitioners? The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.

Objective This paper examines the implementation and implications of four development and research initiatives, collectively titled the Curriculum Renewal Studies program (CRS), occurring over a 6-year period ending in 2015 and focusing on interprofessional education (IPE) within Australian pre-registration health professional education. Methods The CRS was developed as an action-focused and participatory program of studies. This research and development program used a mixed-methods approach. Structured survey, interviews and extensive documentary analyses were supplemented by semi-structured interviews, focus groups, large group consultations and consensus building methods. Narrative accounts of participants’ experiences and an approach to the future development of Australian IPE were developed. Results Detailed accounts of existing Australian IPE curricula and educational activity were developed. These accounts were published and used in several settings to support curriculum and national workforce development. Reflective activities engaging with the findings facilitated the development of a national approach to the future development of Australian IPE – a national approach focused on coordinated and collective governance and development. Conclusion This paper outlines the design of an innovative approach to national IPE governance and development. It explores how ideas drawn from sociocultural theories were used to guide the choice of methods and to enrich data analysis. Finally, the paper reflects on the implications of CRS findings for health professional education, workforce development and the future of Australian IPE. What is known about the topic? IPE to enable the achievement of interprofessional and collaborative practice capabilities is widely accepted and promoted. However, many problems exist in embedding and sustaining IPE as a system-wide element of health professional education. How these implementation problems can be successfully addressed is a health service and education development priority. What does this paper add? The paper presents a summary of how Australian IPE was conceptualised, developed and delivered across 26 universities during the period of the four CRS studies. It points to strengths and limitations of existing IPE. An innovative approach to the future development of Australian IPE is presented. The importance of sociocultural factors in the development of practitioner identity and practice development is identified. What are the implications for practitioners? The findings of the CRS program present a challenging view of current Australian IPE activity and what will be required to meet industry and health workforce expectations related to the development of an Australian interprofessional- and collaborative-practice-capable workforce. Although the directions identified pose considerable challenges for the higher education and health sectors, they also provide a consensus-based approach to the future development of Australian IPE. As such they can be used as a blueprint for national development.

Objective To develop and examine a profile of the demographic, hospital admission and clinical characteristics of high users of hospital resources within a cohort of privately insured Australians. Methods Hospital admissions claims data from a group of private health insurance funds were analysed. The top 1% of hospital users were selected based on three measures of resource utilisation: number of admissions, total bed days and total insurance benefits paid. The demographic, hospital admission and clinical characteristics data were compared for these three measures of resource utilisation. Results Compared with the general insured population, the three high-use cohorts are older, have more public hospital admissions and have more same-day admissions. The three high-use cohorts have the same top five principal diagnosis categories. These five categories account for more than two-thirds of admissions. The top 1% of users is responsible for a large proportion of total resource utilisation, accounting for 13% of total costs and 21% of total bed days. Conclusions The highest users of hospital resources have a distinct profile, accounting for a large proportion of total resource utilisation for a narrow range of health conditions. The age and hospital admission profile of this group suggest both policy and service considerations for the targeting of interventions to support this high-needs group. What is known about this topic? Statistics are regularly published on the uptake and use of private health insurance in Australia but there is little detailed information on resource utilisation in specific subgroups, particularly those with the highest levels of hospitalisation. What does this paper add? This paper provides a profile of high resource utilisation among a privately insured cohort, describing demographic, hospital admission and clinical characteristics across three measures of resource utilisation. Patterns of use are detailed in this profile, for example the top 1% of users have a higher proportion of public hospital admissions as a private patient. The clinical profile of admissions was similar for the three measures of resource utilisation and there was considerable overlap in the individuals categorised in each high-use group. What are the implications for practitioners? The narrow demographic and clinical profile of the high resource utilisation groups shows a chronic disease burden that is different to the focus of current chronic disease policy measures. The high-use conditions identified in this study are less amenable to preventive measures and new strategies may be required to target this high-needs group.

The digital transformation of hospitals in Australia is occurring rapidly in order to facilitate innovation and improve efficiency. Rapid transformation can cause temporary disruption of hospital workflows and staff as processes are adapted to the new digital workflows. The aim of this paper is to outline various types of digital disruption and some strategies for effective management. A large tertiary university hospital recently underwent a rapid, successful roll-out of an integrated electronic medical record (EMR). We observed this transformation and propose several digital disruption “syndromes” to assist with understanding and management during digital transformation: digital deceleration, digital transparency, digital hypervigilance, data discordance, digital churn and post-digital ‘depression’. These ‘syndromes’ are defined and discussed in detail. Successful management of this temporary digital disruption is important to ensure a successful transition to a digital platform. What is known about this topic? Digital disruption is defined as the changes facilitated by digital technologies that occur at a pace and magnitude that disrupt established ways of value creation, social interactions, doing business and more generally our thinking. Increasing numbers of Australian hospitals are implementing digital solutions to replace traditional paper-based systems for patient care in order to create opportunities for improved care and efficiencies. Such large scale change has the potential to create transient disruption to workflows and staff. Managing this temporary disruption effectively is an important factor in the successful implementation of an EMR. What does this paper add? A large tertiary university hospital recently underwent a successful rapid roll-out of an integrated electronic medical record (EMR) to become Australia’s largest digital hospital over a 3-week period. We observed and assisted with the management of several cultural, behavioural and operational forms of digital disruption which lead us to propose some digital disruption ‘syndromes’. The definition and management of these ‘syndromes’ are discussed in detail. What are the implications for practitioners? Minimising the temporary effects of digital disruption in hospitals requires an understanding that these digital ‘syndromes’ are to be expected and actively managed during large-scale transformation.

Objective Globally, the degree of patient harm occurring in healthcare was first publicised in the 1990s. Although many factors affect patient safety, in the US the Institute of Medicine identified hospital organisational culture as one factor contributing to a reduction in errors. This led to the development of many tools for measuring the safety culture of hospital staff. The aim of the present study was to review the literature on patient safety culture in acute hospitals to identify: (1) how patient safety is viewed by health professionals; (2) whether patient safety culture is perceived differently at the hospital versus ward level; and (3) whether clinicians and managers place the same importance on patient safety. Methods Following a search of electronic databases using OneSearch and a manual search of grey literature, an integrative review method identified 11 articles as being suitable to meet the review’s aims. The search terms of patient safety culture, patient safety and safety climate were used. To ensure relevancy to current practice, the search was restricted to the period 2010–15. Results Hospital patient safety culture is not a shared vision, because health professional groups have different views. In the present study, 67% of articles examined found doctors to have a poorer perception of the patient safety culture than nurses and allied health professionals. All health professional groups reported a more positive view of their ward safety culture than that of the hospital safety culture. Furthermore, managers of the health professionals reported more positively on patient safety culture than bedside clinicians. Conclusion This review provides an international understanding of health professionals’ views of patient safety. From an Australian context, the review highlights the need for further investigation, because there is a lack of recent Australian literature in the acute hospital setting relating to patient safety culture. What is known about the topic? Globally, many research papers have reported upon the correlation between a positive patient safety culture and a reduction in healthcare errors. What does this paper add? The present integrative review highlights that regardless of the country of origin, there are differences in the way that a hospital patient safety culture is perceived among different health professional groups, particularly between managers and bedside clinicians. What are the implications for practitioners? Individual health professional groups, and managers and clinicians, have different views on the patient safety culture; therefore, training needs to involve everyone to create a shared vision for patient safety.

Objective The aim of the present study was to identify evidence-based strategies in the literature for developing and maintaining a skilled and qualified rural and remote health workforce in Australia to better meet the health care needs of Australian Aboriginal and/or Torres Strait Islander (hereafter Aboriginal) people. Methods A systematic search strategy was implemented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist. Exclusion and inclusion criteria were applied, and 26 papers were included in the study. These 26 papers were critically evaluated and analysed for common findings about the rural health workforce providing services for Aboriginal people. Results There were four key findings of the study: (1) the experience of Aboriginal people in the health workforce affects their engagement with education, training and employment; (2) particular factors affect the effectiveness and longevity of the non-Aboriginal workforce working in Aboriginal health; (3) attitudes and behaviours of the workforce have a direct effect on service delivery design and models in Aboriginal health; and (4) student placements affect the likelihood of applying for rural and remote health jobs in Aboriginal communities after graduation. Each finding has associated evidence-based strategies including those to promote the engagement and retention of Aboriginal staff; training and support for non-Aboriginal health workers; effective service design; and support strategies for effective student placement. Conclusions Strategies are evidenced in the peer-reviewed literature to improve the rural and remote workforce for health delivery for Australian Aboriginal people and should be considered by policy makers, funders and program managers. What is known about the topic? There is a significant amount of peer-reviewed literature about the recruitment and retention of the rural and remote health workforce. What does this paper add? There is a gap in the literature about strategies to improve recruitment and retention of the rural and remote health workforce for health delivery for Australian Aboriginal people. This paper provides evidence-based strategies in four key areas. What are the implications for practitioners? The findings of the present study are relevant for policy makers, funders and program managers in rural and remote Aboriginal health.

Objective The aim of the present study was to describe the process of establishment and coordination of the national Antimicrobial Use and Resistance in Australia (AURA) surveillance system. Methods Existing surveillance programs conducted by health organisations at state or multi-jurisdictional levels were reviewed, and gaps and opportunities identified for the development of a national system. In view of the time frame available as part of the Australian Government Department of Health funding agreement, the strategy used by the Australian Commission on Safety and Quality in Health Care was to commence work with existing surveillance programs, expanding and enhancing them and developing new systems where gaps were identified. Using the specifications of the AURA national system, the data from each of these elements were then analysed and reported. The system provides coverage for the acute and community sectors for antimicrobial use and antimicrobial resistance. Results The AURA surveillance system integrates eight streams of surveillance activities, including passive and targeted surveillance of antimicrobial use and resistance from hospitals (public and private) and the community (general practitioners and aged care homes). A gap was identified in timely surveillance of critical antimicrobial resistances (CARs), which resulted in the development of the national CARAlert system. The first comprehensive analyses of data across the surveillance programs was published in June 2016, providing baseline data for future reports to build on. Conclusion The AURA surveillance system has established the framework and foundation systems for an integrated and comprehensive picture of both antimicrobial use and resistance in Australia over time. National coordination and support will improve data collection, standardisation and analysis, and will facilitate collaboration across the states and territories, the Australian Government and the private sector. AURA publications will inform policy development and clinical decision making and improve consumer awareness of antimicrobial use and resistance. The system will continue to develop as a comprehensive system, with additional data over time, and appropriate clinical and epidemiological review. What is known about this topic? Surveillance of antimicrobial use and resistance is critical to inform effective policy development and public health responses to the growing problem of antimicrobial resistance. Until now, surveillance of antimicrobial use and resistance in Australia has been fragmented, with state and territory and professional group differences in data collection, analysis and reporting. What does this paper add? This paper profiles the development of the AURA surveillance system, the first nationally coordinated surveillance system for antimicrobial use and resistance, and its use of a partnership approach with contributing programs in order to promote participation and to obtain data to inform strategies to prevent and contain antimicrobial resistance. This paper highlights the establishment phase, noting that the system continues to be improved with growing participation from all sectors. What are the implications for practitioners? National surveillance data from the AURA surveillance system provides evidence for action to guide improvements in infection control, antimicrobial prescribing and the prevention and control of antimicrobial resistance across all healthcare sectors. It will also enable trends to be identified and reported on, and have the capability of determining the effect of interventions to improve and rationalise antimicrobial prescribing.

The aim of the present paper was to review the opportunities currently available to health service planners to advance sustainable development in their future-facing roles within health service organisation. Critical challenges and enablers to facilitate health services planners in adopting a pro-environmental lens are discussed. What is known about the topic? Despite its harmful effect on the environment, health has been slower than other industries to embrace the sustainable development agenda. The attitudes and knowledge base of health service planners with regard to environmental sustainability has not been widely studied. For health service planners, embracing pro-environmental considerations in sustainable model of care development is a powerful opportunity to review care paradigms and prepare for the implementation of meaningful, improved health and system efficiency. What does this paper add? This paper advances the case for health service planners to embrace a pro-environmental stance and guides health service leaders in the preparation and implementation of sustainable and improved health and system efficiency. What are the implications for practitioners? Health service planers are in an ideal position to champion the sustainable development agenda as they explore what care is delivered, how care is delivered and where care is delivered. External policy, health service leadership and carbon literacy are advanced as critical contextual factors to facilitate the key role that health service planners can play in building sustainable healthcare organisations.

Objective The Internet provides the general public with information about speech pathology services, including client groups and service delivery models, as well as the professionals providing the services. Although this information assists the general public and other professionals to both access and understand speech pathology services, it also potentially provides information about speech pathology as a prospective career, including the types of people who are speech pathologists (i.e. demographics). The aim of the present study was to collect baseline data on how the speech pathology profession was presented via images on the Internet. Methods A pilot prospective observational study using content analysis methodology was conducted to analyse publicly available Internet images related to the speech pathology profession. The terms ‘Speech Pathology’ and ‘speech pathologist’ to represent both the profession and the professional were used, resulting in the identification of 200 images. These images were considered across a range of areas, including who was in the image (e.g. professional, client, significant other), the technology used and the types of intervention. Results The majority of images showed both a client and a professional (i.e. speech pathologist). While the professional was predominantly presented as female, the gender of the client was more evenly distributed. The clients were more likely to be preschool or school aged, however male speech pathologists were presented as providing therapy to selected age groups (i.e. school aged and younger adults). Images were predominantly of individual therapy and the few group images that were presented were all paediatric. Conclusion Current images of speech pathology continue to portray narrow professional demographics and client groups (e.g. paediatrics). Promoting images of wider scope to fully represent the depth and breadth of speech pathology professional practice may assist in attracting a more diverse group of people into the profession in the future. What is known about the topic? To date, research has not considered the promotional profile of allied health professionals on the Internet. There has been a lack of consideration of whether the way in which the professions are promoted may affect clients accessing allied health services or people entering careers. What does this paper add? This paper raises awareness of the lack of promotion of a diverse workforce in speech pathology and considers how this may affect changing the professional demographics in the future. It also provides a starting point for documentation in the form of a baseline for tracking future changes. It allows consideration of the fact that when designing health promotional and educational materials, it is crucial that diversity is displayed in the professional role, the client role and the setting in order to provide information and education to the general public about the health services provided. What are the implications for practitioners? The presentation of narrow demographics of both the professional and client may potentially affect people considering speech pathology as a future career. The appearance of narrow client demographics and diagnosis groups may also deter people from accessing services. For example, if the demonstrated images do not show older people accessing speech pathology services, then this may suggest that services are only for children. The results from the present case example are transferrable to other health professions with similar professional demographic profiles (e.g. occupational therapy). Consideration of the need to display a diverse client profile is relevant to all health and medical services, and demonstrates steps towards inclusiveness and increasing engagement of clients who may be currently less likely to access health services (including people who are Aboriginal or from a culturally and linguistically diverse background).

Objectives The aim of the present study was to explore nurse perceptions of safety climate in acute Australian hospitals. Methods Participants included 420 nurses who have worked on 24 acute wards from six Australian hospitals. The Safety Attitudes Questionnaire (SAQ) Short Form was used to quantify nurse perceptions of safety climate and benchmarked against international data. Generalised linear mixed models were used to explore factors that may influence safety climate. Results On average, 53.5% of nurses held positive attitudes towards job satisfaction followed by teamwork climate (50.5%). There was variability in SAQ domain scores across hospitals. The safety climate and perceptions of hospital management domains also varied across wards within a hospital. Nurses who had worked longer at a hospital were more likely to have poorer perceptions of hospital management (β = –5.2; P = 0.014). Overall, nurse perceptions of safety climate appeared higher than international data. Conclusions The perceptions of nurses working in acute Victorian and New South Wales hospitals varied between hospitals as well as across wards within each hospital. This highlights the importance of surveying all hospital wards and examining the results at the ward level when implementing strategies to improve patient safety and the culture of safety in organisations. What is known about the topic? Prior studies in American nursing samples have shown that hospitals with higher levels of safety climate have a lower relative incidence of preventable patient complications and adverse events. Developing a culture of safety in hospitals may be useful in targeting efforts to improve patient safety. What does this paper add? This paper has shown that the perceptions of safety climate among nurses working in acute Australian hospitals varied between hospitals and across wards within a hospital. Only half the nurses also reported positive attitudes towards job satisfaction and teamwork climate. What are the implications for practitioners? Programs or strategies that aim to enhance teamwork performance and skills may be beneficial to improving the culture of safety in hospitals. Wards may also have their own safety ‘subculture’ that is distinct from the overall hospital safety culture. This highlights the importance of tailoring and targeting quality improvement initiatives at the ward level.

This case study describes the development and implementation of an innovative integrated primary–secondary model of care for people with complex diabetes. The aim of the paper is to present the experiences of clinicians and researchers involved in implementing the ‘Beacon’ model by providing a discussion of the contextual factors, including lessons learned, challenges and solutions. Beacon-type models of community care for people with chronic disease are well placed to deliver on Australia’s health care reform agenda, and this commentary provides rich contextual information relevant to the translation of such models into policy and practice. What is known about the topic? Better integrated clinical models of care with close cooperation between hospital-based specialists and general practitioners (GPs) is fundamental to chronic disease management. What does this paper add? A real world example of the challenges faced in implementing models of integrated care across diverse settings and business models. What are the implications for clinicians? Practice, organisational and external factors including energy clinician leadership and resourcing are critical for translation of evidence into ongoing practice.