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Objective: This study assessed the effect of the frequency of general practitioner (GP) visitation in the 12 months before a 21% consumer copayment increase in the Pharmaceutical Benefits Scheme (PBS; January 2005) on the reduction or discontinuation of statin dispensing for tertiary prevention. Methods: The study used routinely collected, whole-population linked PBS, Medicare, mortality and hospital data from Western Australia. From 2004 to 2005, individuals were classified as having discontinued, reduced or continued their use of statins in the first six months of 2005 following the 21% consumer copayment increase on 1 January 2005. The frequency of GP visits was calculated in 2004 from Medicare data. Multivariate logistic regression models were used to determine the association between GP visits and statin use following the copayment increase. Results: In December 2004, there were 22 495 stable statin users for tertiary prevention of prior coronary heart disease, prior stroke or prior coronary artery revascularisation procedure. Following the copayment increase, patients either discontinued (3%), reduced (12%) or continued (85%) their statins. Individuals who visited a GP three or more times in 2004 were 47% less likely to discontinue their statins in 2005 than people attending only once. Subgroup analysis showed the effect was apparent in men, and long-term or new statin users. The frequency of GP visits did not affect the proportion of patients reducing their statin therapy. Conclusions: Patients who visited their GP at least three times per year had a lower risk of ceasing their statins in the year following the copayment increase. GPs can help patients maintain treatment following rises in medicines costs. What is known about the topic?: Following the 21% increase in medication copayment in 2005, individuals discontinued or reduced their statin usage, including for tertiary prevention. What does this paper add?: Patients who visited their GP at least three times per year were less likely to discontinue their statin therapy for tertiary prevention following a large copayment increase. What are the implications for practitioners?: This paper identifies the important role that GPs have in maintaining the continued use of important medications following rises in medicines costs. [ABSTRACT FROM AUTHOR]

Objectives: This study evaluated multiple computed tomography (CT) workforce models to identify any implications on efficiency (length of stay, scan frequency and workforce cost) and scanning radiographer interruptions through substituting or supplementing with a trained CT assistant. Methods: The study was conducted in a CT unit of a tertiary Queensland hospital and prospectively compared four workforce models, including usual practice: Model 1 used an administrative assistant (AA) and one radiographer; Model 2 substituted a medical imaging assistant (MIA) for the AA; Model 3 was usual practice, consisting of two radiographers; and Model 4 included two radiographers, with a supplemented MIA. Observational data were collected over 7 days per model and were cross-checked against electronic records. Data for interruption type and frequency, as well as scan type and duration, were collected. Annual workforce costs were calculated as measures of efficiency. Results: Similar scan frequency and parameters (complexity) occurred across all models, averaging 164 scans (interquartile range 160–172 scans) each. The median times from patient arrival to examination completion in Models 1–4 were 47, 35, 46 and 33 min respectively. There were between 34 and 104 interruptions per day across all models, with the 'assistant role' fielding the largest proportion. Model 4 demonstrated the highest workforce cost, and Model 2 the lowest. Conclusion: This study demonstrated that assistant models offer similar patient throughput to usual practice at a reduced cost. Model 2 was the most efficient of all two-staff models (Models 1–3), offering the cheapest workforce, slightly higher throughput and faster examination times. Not surprisingly, the additional staff model (Model 4) offered greater overall examination times and throughput, with fewer interruptions, although workforce cost and possible role ambiguity were both limitations of this model. These findings may assist decision makers in selecting the optimal workforce design for their own individual contexts. What is known about the topic?: Innovative solutions are required to address ongoing health workforce sustainability concerns. Workforce substitution models using trained assistants have demonstrated numerous benefits internationally, with translation to the Australian allied health setting showing promise. What does this paper add?: Building on existing research, this study provides clinical workforce alternatives that maintain patient throughput while offering cost efficiencies. This study also quantified the many daily interruptions that occur within the CT setting, highlighting a potential clinical risk. To the best of our knowledge, this study is the first to empirically test the use of allied health assistants within CT. What are the implications for practitioners?: Role substitution in CT may offer solutions to skills shortages, increasing expenditure and service demand. Incorporating appropriate assistant workforce models can maintain throughput while demonstrating implications for efficiency and interruptions, potentially affecting staff stress and burnout. In addition, the assistant's scope and accepted level of interruptions should be considerations when choosing the most appropriate model. [ABSTRACT FROM AUTHOR]

Objective. To estimate the risk of functional decline after discharge for older people presenting to, and discharged from, a large emergency department (ED) of a tertiary hospital. Methods. The cohort was generated by consecutive sampling of non-Indigenous males and females aged 65 years or over or Aboriginal and Torres Strait Islander males and females aged 45 years or more, without diagnosed dementia, who were living independently in the community before presenting at ED and who were not admitted to hospital as an inpatient after presenting to ED. The hospital assessment risk profile (HARP) was administered to all eligible participants. Sociodemographic information was collected. Results. Approximately 40 patients per day over two 14-week data collection periods were potentially eligible for inclusion in the study. In total, 597 (17.6% of individuals who presented to ED) were eligible, agreed to participate and continued to be eligible on discharge from ED. Their HARP scores suggested that ~52% were at-risk of functional decline (14.1% high risk, 38.5% intermediate risk). Conclusions. Elderly patients present to and are discharged from ED every day. The routinely administered HARP instrument scores suggested that approximately half these individuals were at-risk of functional decline in one large hospital ED. Given this instrument's moderate diagnostic accuracy, the true figure may be higher. We suggest that all over-65 year olds presenting at ED without being admitted as an inpatient should be considered for routine screening for potential downstream functional decline, and for intervention if indicated. What is known about the topic? Older individuals often present to ED in lieu of consulting a general medical practitioner, and are not admitted to a hospital bed. Patient demographics, functional and mental capacity and reasons for presentation may be flags for functional decline in the coming months. These could be used by ED staff to implement targeted assessment and intervention. What does this paper add? This paper highlights the high percentage of older individuals who, at time of ED presentation, are at-risk of downstream functional decline. What are the implications for practitioners? Older people who are discharged from ED without a hospital admission may 'slip through the net', as an ED presentation presents a limited window of opportunity for ED staff to undertake targeted assessment, and intervention, to address the potential for downstream functional decline. The busy nature of ED, resource implications and the range of presenting conditions of older people may preclude this. This research suggests a reality that a large percentage of older people who present at ED but do not require a subsequent hospital admission have the potential for functional decline after discharge. Addressing this, in terms of specific screening processes and interventions, requires a rethink of hospital and community resources, and relationships. [ABSTRACT FROM AUTHOR]

Objective. To examine personal and social demographics, and rehabilitation discharge outcomes of dysvascular and non-vascular lower limb amputees. Methods. In total, 425 lower limb amputation inpatient rehabilitation admissions (335 individuals) from 2005 to 2011 were examined. Admission and discharge descriptive statistics (frequency, percentages) were calculated and compared by aetiology. Results. Participants were male (74%), aged 65 years (s.d. 14), born in Australia (72%), had predominantly dysvascular aetiology (80%) and a median length of stay 48 days (interquartile range (IQR): 25-76). Following amputation, 56% received prostheses for mobility, 21% (n = 89) changed residence and 28% (n = 116) required community services. Dysvascular amputees were older (mean 67 years, s.d. 12 vs 54 years, s.d. 16; P< 0.001) and recorded lower functional independence measure -- motor scores at admission (z = 3.61, P<0.001) and discharge (z =4.52, P<0.001). More nonvascular amputees worked before amputation (43% vs 11%; P< 0.001), were prescribed a prosthesis by discharge (73% vs 52%; P< 0.001) and had a shorter length of stay (7 days, 95% confidence interval: -3 to 17), although this was not statistically significant. Conclusions. Differences exist in social and demographic outcomes between dysvascular and non-vascular lower limb amputees. What is known about the topic? Lower limb amputation occurs due to various aetiologies. What does this paper add? Lower limb amputee rehabilitation over 7 years was investigated, comprising 425 admissions, 80% due to dysvascular aetiology. Personal and social demographics, and discharge outcomes are compared by aetiology. What are the implications for practitioners? Demographic and discharge outcome differences exist between dysvascular and non-vascular lower limb amputees. Twenty-one percent were required to change residence and 28% required additional social supports. Discharge planning should begin as soon as possible to limit time spent waiting for new accommodation or major modifications for current homes. Lower limb amputees are not homogeneous, so care should be taken if extrapolating from combined amputee aetiologies or from one aetiology to another. [ABSTRACT FROM AUTHOR]

Objective. This paper describes the effects of a maternity consumer representative training program on participants' confidence to fulfil this role and engagement in representative activities. Methods. The present study was a descriptive, pre-post evaluation design with a 3-month follow-up. Fifty-eight people completed the program and 55 agreed to participate in the evaluation. Participants completed questionnaires to assess confidence to undertake consumer representative roles and reported on their engagement with consumer activities. Results. Participants' perceived confidence to function in the role of consumer representative differed significantly before and after the workshop (F(2,18) = 7.057, P < 0.001), as did confidence in decision making (F (2,16) = 7.615, P = 0.005), confidence in negotiating outcomes and liaising with key people (F(2,18) = 7.154, P = 0.005), and confidence in making use of relevant networks (F (2,18) = 4.319, P = 0.029). There was a decline in confidence at 3 months, with confidence at this time no longer significantly different from that at the time of recruitment. Engagement with consumer organisations increased by 45% compared with rates at commencement of the project. Conclusions. The program enhanced participants' confidence to fulfil a maternity consumer representative role but was not sustained. Further research is needed as to how to best support maternity consumer representatives and assess their contribution to promoting woman-centred care. [ABSTRACT FROM AUTHOR]

The Australian government's commitment to health service reform has placed general practice at the centre of its agenda to manage chronic disease. Concerns about the capacity of GPs to meet the growing chronic disease burden has stimulated the implementation and testing of new models of care that better utilise practice nurses (PN). This paper reports on a mixed-methods study nested within a larger study that trialled the feasibility and acceptability of a new model of nurse-led chronic disease management in three general practices. Patients over 18 years of age with type 2 diabetes, hypertension or stable ischaemic heart disease were randomised into PN-led or usual GP-led care. Primary outcomes were self-reported quality of life and perceptions of the model's feasibility and acceptability from the perspective of patients and GPs. Over the 12-month study quality of life decreased but the trend between groups was not statistically different. Qualitative data indicate that the PN-led model was acceptable and feasible to GPs and patients. It is possible to extend the scope of PN care to lead the routine clinical management of patients' stable chronic diseases. All GPs identified significant advantages to the model and elected to continue with the PN-led care after our study concluded. [ABSTRACT FROM AUTHOR]

Rural communities continue to experience shortages of doctors, placing increased work demands on the existing rural medical workforce. This paper investigates patterns of geographical variation in the workload and work activities of GPs by community size. Our data comes from wave 1 of the Medicine in Australia: Balancing Employment and Life longitudinal study, a national study of Australian doctors. Self-reported hours worked per usual week across eight workplace settings and on-call/ after-hours workload per usual week were analysed against seven community size categories. Our results showed that a GP's total hours worked per week consistently increases as community size decreases, ranging from 38.6 up to 45.6h in small communities, with most differences attributable to work activities of rural GPs in public hospitals. Higher on-call workload is also significantly associated with smaller rural communities, with the likelihood of GPs attending more than one callout per week ranging from 9% for metropolitan GPs up to 48-58% in small rural communities. Our study is the first to separate hours worked into different work activities whilst adjusting for community size and demographics, providing significantly greater insight to the increased hours worked, more diverse activities and significant after-hours demands experienced by current rural GPs. [ABSTRACT FROM AUTHOR]

Objective. To determine rates and risk factors for self-discharge by Aboriginal medical inpatients at Alice Springs Hospital. Methods. Prospective cohort study. Interviews were conducted in primary language by Aboriginal Liaison Officers, from July 2006 to August 2007. Topics included understanding of diagnosis, satisfaction with services and perceptions of staff and environment. Risk factors for self-discharge were then determined prospectively. Results. During the study period 202 (14.7%) of 1380 patients admitted to general medical units at Alice Springs Hospital, were interviewed. Self-discharge rates for all admissions were significantly lower during the study period than they had been previously (pre-study, mean 22.9 ± standard error 0.3%; study, 17.0 ± 0.2%) (P < 0.001). Most interviewees (73.4%) did not know their reason for admission (73.4%) or estimated length of stay (82.3%). Forty interviewees (19.8%) self-discharged. Mean monthly self-discharge rates differed between the three medical units (Unit A, 13.9 ± 0.3%; Unit B, 17.3 ± 1.37%; Unit C, 20.0 ± 0.4%) (P = 0.005). Multivariable predictors of self-discharge included male sex (hazard ratio (HR) 2.4; 95% confidence interval (CI) 1.1, 5.2), a past history of self-discharge (HR 3.2; 95%CI 1.5, 6), planned transfer to a tertiary referral centre (HR 3.8; 95%CI 1.3-7.4) and a desire to drink alcohol (HR 4.5; 95%CI 1.8-10.2). Conclusions. Physician, institutional and patient factors all contribute to self-discharge. Improving cultural safety may be the key to lowering self-discharge rates. What is known about the topic? Rates of self-discharge by Aboriginal adults in Central Australia are the highest reported worldwide. Previous studies have been retrospective and focussed on patient demographics without addressing the environmental and cultural contexts in which self-discharge occurs. What does this paper add? In this acute care setting, we found a pervasive failure to communicate effectively with Aboriginal patients. Consequently, most patients were unaware of their diagnosis or length of stay. Self-discharge was a common practice; nearly half of all previously admitted patients had self-discharged in the past. We demonstrate that physician, hospital and patient factors all contribute to this practice. Prospectively determined risk factors included the treating medical team, the need for transfer outside Central Australia, and patient factors such as male gender and alcohol dependence. Self-discharge rates fell significantly with Aboriginal Liaison involvement. What are the implications for practitioners? Cross-cultural communication skills must be markedly improved among medical staff caring for this marginalised population. Critical to reducing rates of self-discharge are improvements in institutional cultural safety by involving Aboriginal Liaison Officers and family members. However, persistently high self-discharge rates suggest a need to redirect medical services to a more culturally appropriate community-based model of care. [ABSTRACT FROM AUTHOR]