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Objective: The aim of the present study was to quantify and compare patient health literacy between privately insured and public orthopaedic patients. Methods: As part of the present cross-sectional study, elective postoperative orthopaedic patients across two sites were recruited and asked to complete a questionnaire at the first postoperative out-patient review. Patients were divided into three groups: (1) a public group (Public); (2) a private group (Private-pre); and (3) a private group that completed the questionnaire immediately after the out-patient review (Private-post). The questionnaire consisted of six questions regarding surgical management, expected recovery time and postoperative instructions. Patients were further asked to grade their satisfaction regarding information received throughout their management. Results: In all, 150 patients completed the questionnaire, 50 in each of the three groups. Patients in the Public, Private-pre and Private-post groups answered a mean 2.74, 3.24 and 4.70 of 6 questions correctly respectively. The Private-pre group was 1.46-fold more likely to demonstrate correct health literacy than the Public group, whereas the Private-post group was 2.44-fold more likely to demonstrate improved health literacy than the Private-pre group. Patient satisfaction with information received was not associated with health literacy. Conclusion: Limited health literacy in orthopaedic patients continues to be an area of concern. Both private and public orthopaedic patients demonstrated poor health literacy, but private patients demonstrated significant improvement after the out-patient review. What is known about the topic?: Limited health literacy is a growing public health issue worldwide, with previous literature demonstrating a prevalence of low health literacy of 26% and marginal health literacy of 20% among all patient populations. Of concern, limited health literacy has been shown to result in a range of adverse health outcomes, including increased mortality and chronic disease morbidity. It has also been associated with an increased rate of hospitalisation and use of healthcare resources. Previous work in the orthopaedic trauma setting has found poor levels of health literacy and poor understanding of diagnosis, management and prognosis in the Australian public health system. Promisingly, it has been shown that simple, targeted interventions can improve patient health literacy. What does this paper add?: This study further highlights that health literacy exhibited by orthopaedic patients is poor, particularly among patients in the public healthcare system. The present study is the first to have demonstrated that health literacy is poor among patients in both the public and private healthcare systems, despite these patients having distinctly different demographics. Promisingly, the present study shows that, unlike public orthopaedic out-patient review, private orthopaedic out-patient review appears to be effective in increasing patient health literacy regarding their orthopaedic condition and its management. What are the implications for practitioners?: Health literacy is essential for patients to effectively communicate with doctors and achieve good health outcomes. Healthcare professionals need to be aware that a large proportion of patients have poor health literacy and difficulty understanding health-related information, particularly pertaining to that surrounding diagnosis, management and prognosis. This study highlights the need for healthcare professionals to ensure that they communicate with patients at an appropriate level to ensure patient understanding during the pre-, peri- and postoperative stages of management. Further, healthcare professionals should be aware that there is potential to improve patient health literacy at routine out-patient review, provided that this opportunity is used as an educational resource. [ABSTRACT FROM AUTHOR]

Objective: To compare annual costs of an intervention for acutely unwell older residents in residential age care facilities (RACFs) with usual care. The intervention, the Aged Care Emergency (ACE) program, includes telephone clinical support aimed to reduce avoidable emergency department (ED) presentations by RACF residents. Methods: This costing of the ACE intervention examines the perspective of service providers: RACFs, Hunter Medicare Local, the Ambulance Service of New South Wales, and EDs in the Hunter New England Local Health District. ACE was implemented in 69 RACFs in the Hunter region of NSW, Australia. Analysis used 14 weeks of ACE and ED service data (June–September 2014). The main outcome measure was the net cost and saving from ACE compared with usual care. It is based on the opportunity cost of implementing ACE and the opportunity savings of ED presentations avoided. Results: Our analysis estimated that 981 avoided ED presentations could be attributed to ACE annually. Compared with usual care, ACE saved an estimated A$921 214. Conclusions: The ACE service supported a reduction in avoidable ED presentations and ambulance transfers among RACF residents. It generated a cost saving to health service providers, allowing reallocation of healthcare resources. What is known about the topic?: Residents from RACFs are at risk of further deterioration when admitted to hospital, with high rates of delirium, falls, and medication errors. For this cohort, some conditions can be managed in the RACF without hospital transfer. By addressing avoidable presentations to EDs there is an opportunity to improve ED efficiency as well as providing care that is consistent with the resident's goals of care. RACFs generate some avoidable ED presentations for residents who may be more appropriately treated in situ. What does this paper add?: Telephone triaging with nursing support and training is a means by which ED presentations from RACFs can be reduced. One of the consequences of this intervention is 'cost avoided', largely through savings on ambulance costs. What are the implications for practitioners?: Unnecessary transfer from RACFs to ED can be avoided through a multicomponent program that includes telephone support with cost-saving implications for EDs and ambulance services. [ABSTRACT FROM AUTHOR]

Objectives: To ascertain Australian multistate prevalence and incidence of five commonly collected clinical indicators of aged-care home quality and to measure associations between these clinical indicators and levels of care needs and consumer and staff satisfaction. Methods: A retrospective analysis of national audit data collected from 426 facilities between 2015 and 2016 was performed. Regression models were used to examine associations between five clinical indicators (falls, pressure injury, physical restraint, unplanned weight loss and polypharmacy) and level of care needs measured by the Aged Care Funding Instrument (ACFI) and consumer and care staff survey responses. Results: With the exception of polypharmacy, commonly collected negative clinical outcomes were rare events. Compared with care homes with <25% of residents having high-level care needs (high ACFI), homes with 25<75% high-ACFI residents had more occurrences of all negative clinical outcomes except pressure injury. Homes with ≥75% high-ACFI residents reported the highest rates of polypharmacy (odds ratio 1.48, 95% confidence interval 1.39 – 1.57). Falls, unplanned weight loss and pressure injury were inversely associated with satisfaction scores adjusted for residents' level of care needs. Conclusions: This first Australian study of multistate clinical indicator data suggests interpretation of clinical indicators of aged-care home quality requires consideration of the level of residents' care needs. What is known about the topic?: Many Australian aged-care providers use quality indicators (QI) through benchmarking companies or in-house programs. The five most widely used aged-care clinical QIs in Australia are falls, pressure injury, physical restraint, unplanned weight loss and polypharmacy. Prevalence and incidence of these QIs are highly variable among Australian studies. A consistent message in the international literature is that residents' clinical characteristics influence QI outcomes at baseline and may continue to influence outcomes over time. Study of associations between Australian aged-care home characteristics and QI outcomes has been limited. What does this paper add?: This is the first Australian study of multistate clinical QI data. It is also the first to consider the level of resident care needs in the interpretation of clinical QI outcomes and exploration of the association between level of consumer and staff satisfaction and QI outcomes. What are the implications for practitioners?: Understanding the connections between aged-care home characteristics, consumer and staff perceptions and clinical QIs is crucial in the meaningful interpretation of QI outcomes in context. With the recent introduction of the National Aged Care Quality Indicator Program, it is timely to review national policy, to gauge current quality of care and the measure of care quality in the sector, and to develop directions for possible research to inform and resolve debates regarding the potential influence and unplanned effects that such a program may have. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the present study was to assess comparative emergency department (ED) resource utilisation across age groups. Methods: A retrospective analysis of data collected in the National Non-admitted Patient Emergency Department Care Database was undertaken to assess comparative ED resource utilisation across six age groups (0–14, 15–35, 36–64, 65–74, 75–84 and ≥85 years) with previously used surrogate markers of ED resource utilisation. Results: Older people had significantly higher resource utilisation for their individual ED episodes of care than younger people, with the effect increasing with advancing age. Conclusion: With ED care of older people demonstrated to be more resource intensive than care for younger people, the projected increase in older person presentations anticipated with population aging will have a magnified effect on ED services. These predicted changes in demand for ED care will only be able to be optimally managed if Australian health policy, ED funding instruments and ED models of care are adjusted to take into account the specific care and resource needs of older people. What is known about the topic?: Current Australian ED funding models do not adjust for patient age. Several regional studies have suggested higher resource utilisation of ED patients aged ≥65 years. Anticipated rapid population aging mandates that contribution of age to ED visit resource utilisation be further explored. What does this paper add?: The present study of national Australian ED presentations compared ED resource utilisation across age groups using surrogate markers of ED cost. Older people were found to have significantly higher resource utilisation in the ED, with the effect increasing further with advancing age. What are the implications for practitioners?: The higher resource utilisation of older people in the ED warrants a review of current ED funding models to ensure that they will continue to meet the needs of an aging population. [ABSTRACT FROM AUTHOR]

Objective: HealthPathways (HPW) is an international web-based information portal that provides health practitioners with guidelines and referral pathways to specialists and services. The present study explored usage of HPW by general practitioners (GPs) in the Barwon region, south-west Victoria, and any benefits and barriers to its use. Methods: Approximately 421 GPs provide services in 86 clinics across the Barwon region, south-west Victoria and Barwon Health is the public health service providing acute, subacute, residential aged care and community health services to approximately 350 000 people. The present study was a mixed-methods analysis of all GPs in the region, who were invited to complete a survey in two waves (2014 and 2016) and participate in focus groups. Data were survey/questionnaire (fixed response and free text options, analysed with descriptive statistics and content analysis), and focus groups (interview and facilitated group discussion, analysed using the principles of thematic analysis). Results: Most GPs surveyed used HPW and usage increased over time from 2014 to 2016 (67% vs 77% respectively). Junior GPs used HPW more often than the more experienced practitioners. GPs reported that HPW was easy to access and navigate, improved their knowledge of local services, improved their confidence, changed their clinical management and saved them time. Main barriers to use of HPW were: GPs did not think to look at HPW, or simply did not know about it. Conclusions: HPW has the potential to improve patient management and health outcomes, and use of HPW is increasing over time. What is known about the topic?: Initiatives such as HPW are viewed positively by clinicians and have the potential to address challenges at the primary–secondary care interface, specifically, referral to secondary specialists. What does this paper add?: Proof of concept that the ongoing availability of localised HPW for common clinical conditions improves GP usage of HPW and has increased access to HPW as the first source of clinical information. Benefits and barriers to use have been identified. What are the implications for practitioners?: HPW improves knowledge of local services and provides GPs with easy access to referral pathways. [ABSTRACT FROM AUTHOR]

Objective: Nursing and allied health professionals (AHPs) are in an ideal position to promote physical activity (PA) as part of their health care provision. The aim of this study was to investigate current promotion and knowledge of PA among people in these disciplines. Methods: A cross-sectional online survey of practicing Australian physiotherapists, nurses, exercise physiologists, occupational therapists, dietitians and pharmacists was conducted in 2016. Results: A total of 433 nurses and AHPs completed the survey. All disciplines agreed that providing PA advice was part of their role, although nurses were less likely to agree. All disciplines felt they had the skills to promote PA but nurses were more likely to report a lack of time as a barrier. Physiotherapists and exercise physiologists were more confident giving PA advice to patients. Most health professionals (68%) were aware of the PA guidelines, although only 16% were accurately able to describe all relevant components. In logistic regression modelling, women and those working in public hospitals were less likely to encourage PA. Awareness of the PA guidelines doubled the odds of encouraging PA in patients (odds ratio 2.01, 95% confidence interval 1.18–3.43). Conclusions: Australian nurses and AHPs perceive that PA promotion is part of their role, however few have specific knowledge of the PA guidelines. To increase PA promotion by nurses and AHPs awareness of the PA guidelines appears to be essential. What is known about the topic?: Nurses and AHPs are in an ideal position to promote PA, although there is limited evidence of their PA promotion and knowledge. What does the paper add?: Australian nurses and AHPs are confident and think it is feasible to promote PA to patients in several healthcare settings but many lack sufficient PA knowledge, limiting their PA promotion. What are the implications for practitioners?: Increasing PA knowledge of nurses and AHPs could generate increased levels of PA in the Australian population and improve national health and wellbeing. [ABSTRACT FROM AUTHOR]

Objective: High caseload is considered one of the most important factors for good outcomes after high-risk surgeries such as oesophagectomy. However, many Australian centres perform low volumes of oesophagectomies due to demographics. The aim of the present study was to audit outcome after oesophagectomy in an Australian low-volume centre over a period of 13 years and to discuss potential contributors to outcome other than just case volume. Methods: Perioperative and long-term outcomes of all oesophagectomies over a 13-year period in a low-volume Australian tertiary care centre were analysed retrospectively. Data were compared in subgroups of patients in two separate time periods: 2000–05 (n = 23) and 2006–12 (n = 24). Results: There were two perioperative deaths over the entire 13-year period with no postoperative mortality in the last decade. The complication and long-term survival rates for each of the two separate time periods were similar to those from high-volume centres, more so in the second half of the study period. Conclusions: The data suggest that under specific conditions, oesophagectomies can be safely performed even in smaller- or low-volume centres in Australia. The policy of centralisation for these procedures in Australia needs to be carefully tailored to the needs of the population, clinical outcomes, cost-effectiveness and optimal utilisation of existing facilities rather than on caseload alone. What is known about the topic?: High caseload is considered one of the most important factors for good outcomes after oesophagectomy and a driving force behind centralisation of this procedure. However, other factors may also affect outcome – such as availability of experienced surgeons, specialist nurses, interventional radiology, gastroenterology, etc. What does this paper add?: With the availability of appropriate levels of expertise, infrastructure and specialist nursing staff as is the case in most Australian tertiary centres, good perioperative outcomes can be obtained despite low volumes. Case load only should not be used as a surrogate marker of quality. What are the implications for practitioners?: The policy of centralisation for oesophagectomy in Australia needs to be carefully thought out on the basis of population demographics, outcomes and cost-effectiveness, with the appropriate use of existing facilities, rather than on a caseload basis alone. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to gain an understanding of the factors associated with unplanned hospital readmission within 28 days of acute care discharge from a major Australian health service. Methods: A retrospective study of 20 575 acute care discharges from 1 August to 31 December 2015 was conducted using administrative databases. Patient, index admission and readmission characteristics were evaluated for their association with unplanned readmission in ≤28 days. Results: The unplanned readmission rate was 7.4% (n = 1528) and 11.1% of readmitted patients were returned within 1 day. The factors associated with increased risk of unplanned readmission in ≤28 days for all patients were age ≥65 years (odds ratio (OR) 1.3), emergency index admission (OR 1.6), Charlson comorbidity index >1 (OR 1.1–1.9), the presence of chronic disease (OR 1.4) or complications (OR 1.8) during the index admission, index admission length of stay (LOS) >2 days (OR 1.4–1.8), hospital admission(s) (OR 1.7–10.86) or emergency department (ED) attendance(s) (OR 1.8–5.2) in the 6 months preceding the index admission and health service site (OR 1.2–1.6). However, the factors associated with increased risk of unplanned readmission ≤28 days changed with each patient group (adult medical, adult surgical, obstetric and paediatric). Conclusions: There were specific patient and index admission characteristics associated with increased risk of unplanned readmission in ≤28 days; however, these characteristics varied between patient groups, highlighting the need for tailored interventions. What is known about the topic?: Unplanned hospital readmissions within 28 days of hospital discharge are considered an indicator of quality and safety of health care. What does this paper add?: The factors associated with increased risk of unplanned readmission in ≤28 days varied between patient groups, so a 'one size fits all approach' to reducing unplanned readmissions may not be effective. Older adult medical patients had the highest rate of unplanned readmissions and those with Charlson comorbidity index ≥4, an index admission LOS >2 days, left against advice and hospital admission(s) or ED attendance(s) in the 6 months preceding index admission and discharge from larger sites within the health service were at highest risk of unplanned readmission. What are the implications for practitioners?: One in seven discharges resulted in an unplanned readmission in ≤28 days and one in 10 unplanned readmissions occurred within 1 day of discharge. Although some patient and hospital characteristics were associated with increased risk of unplanned readmission in ≤28 days, statistical modelling shows there are other factors affecting the risk of readmission that remain unknown and need further investigation. Future work related to preventing unplanned readmissions in ≤28 days should consider inclusion of health professional, system and social factors in risk assessments. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to describe the elderly population of the Northern Territory (NT), explore the challenges of delivering aged care services to this population and implications for the acute care sector. Methods: Data gathered from a variety of sources were used to describe the demographic and health profile of elderly Territorians, the aged care structure and services in the NT, and admission trends of elderly patients in NT hospitals. Information regarding NT community and residential aged care services was sourced from government reports. NT public hospital admissions from 2001 to 2015 were adjusted by the estimated Aboriginal and non-Aboriginal populations. Results: In 2015, elderly people constituted 9.2% of the NT population and this number is predicted to increase. Between 2001 and 2015, the number and rate of elderly admissions to NT public hospitals increased significantly. Compared with other jurisdictions, aged care in the NT is dominated by community services, which are of limited scope. Important geographical and economic factors affect the availability of residential aged care beds. This, in turn, affects the ability of elderly people to transition from hospital settings. Conclusions: The NT has a relatively small but growing elderly population with increasing needs. This population is markedly different compared with its counterparts in other Australian states and territories, but receives aged care services based on national policies. Recent changes to community-based services and increases in residential beds should improve services and care, although remaining challenges and gaps need to be addressed. What is known about the topic?: Increasing health and care needs of elderly people will place significant stress across the health and aged care system. In Australia, most aged care services are apportioned and funded under a national system. The NT has a markedly different population profile compared with the rest of Australia, which gives rise to unique considerations, but its aged care structure is based on nationally developed policies. What does this paper add?: Elderly people in the NT are increasingly using acute care services. Aged care services in the NT have higher ratios of community-based services to residential aged care facilities (RACF) as a consequence of a 'younger' cohort of Aboriginal elderly people who live remotely. In addition, economic factors affect the low number of RACF places. As evidenced in past years, a small pool of beds can adversely affect the numbers and length of stay of elderly people waiting in hospitals. What are the implications for practitioners?: The NT has a small but growing population of elderly people, which will place an increasing burden on acute care services that are ill equipped to manage their specific needs. Recent RACF and flexible care bed approvals may alleviate past difficulties to transition hospital patients awaiting RACF placement. Significant changes at the national level to community-based care services that increase flexibility for providers may bring about better outcomes for remote elderly recipients. However, high costs and issues with remote servicing will remain. Psychogeriatrics remains a major underserviced area in the NT with no prospective solution. [ABSTRACT FROM AUTHOR]

Objective: Effective health care for older people with complex health needs requires a diverse range of healthcare professionals working together. The Building Partnerships Framework of the New South Wales Agency for Clinical Innovation seeks to promote collaboration and integration among service providers. The aim of the present study was to inform implementation and evaluation of the Framework. Methods: Data from the 45 and Up Study was linked with deaths and service data from hospitalisations and the Medicare Benefits Schedule (MBS). Participants with a hospitalisation for conditions representing 'geriatric syndrome' were allocated to a complex needs group; the remainder were allocated to a comparison group. Hospital admissions and MBS services use were modelled using log-linear Poisson regression. Results: Multivariate analysis showed that the rate of hospitalisation in the 2 years following index admission for the complex needs group was 18% (95% confidence interval (CI) 1.12–1.24) greater than the comparison group and specialist physician attendance was 13% (95% CI 1.06 – 1.21) greater. The rate of general practitioner (GP) attendances was 2% (95% CI 0.97–1.07) greater in the complex needs group, but this was not statistically significant. Discussion: The greater rates of hospitalisation and specialist service use, the absence of a similar finding for GP services and the prominence of the role of primary care in service integration literature, policy and strategy underscore the importance of careful planning, consultation and inclusiveness in the development and implementation of integrated care policy. What is known about the topic?: Older people with complex health needs are significant consumers of primary and secondary health services and benefit from well-planned and coordinated care. What does this paper add?: The findings presented here indicate that although hospitals and specialist physicians provide a significantly greater volume of services to people with complex health needs, GPs do not. Within the limitations of the present study, these findings can contribute to integrated care policy and strategy development and implementation. What are the implications for practitioners?: Given the prominence of primary care in service integration literature, policy and strategy and the findings of the present study with regard to the relative level of GP involvement in the management of people with complex needs, careful policy implementation will be required to ensure GPs are able to contribute significantly to coordinated cooperation between health services. [ABSTRACT FROM AUTHOR]

Objective: Limited international evidence suggests general practice registrars' emergency department (ED) referral rates exceed those of established general practitioners (GPs). The aim of the present study was to fill an evidence gap by establishing the prevalence, nature and associations of Australian GP registrar ED referrals. Methods: A cross-sectional analysis was performed of the Registrar Clinical Encounters in Training (ReCEnT) cohort study of GP registrars' consultation experiences, between 2010 and 2015. The outcome factor in logistic regression analysis was referral to an ED. Independent variables included patient-level, registrar-level, practice-level and consultation-level factors. Results: In all, 1161 GP registrars (response rate 95.5%) contributed data from 166 966 consultations, comprising 258 381 individual problems. Based on responses, 0.5% of problems resulted in ED referral, of which nearly 25% comprised chest pain, abdominal pain and fractures. Significant (P < 0.05) associations of ED referral included patient age <15 and >34 years, the patient being new to the registrar, one particular regional training provider (RTP), in-consultation information or assistance being sought and learning goals being generated. Outer regional-, remote- or very remote-based registrars made significantly fewer ED referrals than more urban registrars. Of the problems referred to the ED, 45.5% involved the seeking of in-consultation information or assistance, predominantly from supervisors. Conclusions: Registrars' ED referral rates are nearly twice those of established GPs. The findings of the present study suggest acute illnesses or injuries present registrars with clinical challenges and real learning opportunities, and highlight the importance of continuity of care, even for acute presentations. What is known about the topic?: A GP's decision concerning continued community- versus hospital-based management of acute presentations demands careful consideration of a suite of factors, including implications for patient care and resource expenditure. General practice vocational training is a critical period for the development of GP registrars' long-term patterns of practice. Although limited international evidence suggests GP registrars and early career GPs refer patients to the ED at a higher rate than their more experienced peers, these studies involved small subject numbers and did not investigate associations of registrars making an ED referral. Relevant Australian studies focusing on GP registrars' ED referral patterns are lacking. What does this paper add?: The present ongoing cohort study is the first to establish the patterns of ED referrals made by Australian GP registrars, encompassing five general practice RTPs across five states, with participating registrars practising in urban, rural, remote and very remote practices. Several significant associations were found with GP registrars making ED referrals, including patient age, continuity of care, the registrar's RTP, assistance sought by the registrar and rurality of the registrar's practice. What are the implications for practitioners?: The higher likelihood of GP registrars seeing acute presentations than their more established practice colleagues, coupled with a demonstrated association of registrars seeking in-consultation assistance for such presentations, highlights the importance of GP supervisor accessibility in facilitating ED referral appropriateness and in the development of registrars' safe clinical practice. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to describe process changes in surgical team performance and team members' attitudes to safety culture following hospital relocation and expansion of perioperative services. Methods: The study was a naturalistic study using structured observations and surveys to assess non-technical skills (NTS; i.e. communication, teamwork, situational awareness, decision making and leadership) in surgery. This interrupted time series design used mixed-linear regression models to examine the effect of phase (before and after hospital relocation) on surgical teams' NTS and their processes that may affect performance. Differences in self-reported teamwork and safety climate attitudes were also examined. Results: In all, 186 procedures (100 before and 81 after hospital relocation) were observed across teams working in general, paediatric, orthopaedic and thoracic surgeries. Interobserver agreement ranged from 86% to 95%. An effect of phase was found, indicating that there were significant improvements after relocation in the use of NTS by the teams observed (P = 0.020; 95% confidence interval 1.9–4.7). Conclusions: The improvements seen in surgical teams' NTS performance and safety culture attitudes may be related to the move to a new state-of-the-art perioperative department. What is known about the topic?: Patient safety in surgery relies on optimal team performance, underpinned by effective NTS. What does this paper add?: The NTS of surgical teams may be improved through ergonomic innovations that promote teams' shared mental models. What are the implications for practitioners?: Effective multidisciplinary teamwork relies on a combination of NTS and ergonomic factors, which inherently contribute to team performance and safety climate attitudes. [ABSTRACT FROM AUTHOR]

Objective: The aim of the present study was to explore disposal practices of unwanted medicines in a representative sample of Australian adults, compare this with previous household waste surveys and explore awareness of the National Return and Disposal of Unwanted Medicines (RUM) Project. Methods: A 10-min online survey was developed, piloted and conducted with an existing research panel of adult individuals. Survey questions recorded demographics, the presence of unwanted medicines in the home, medicine disposal practices and concerns about unwanted medicines. Descriptive statistical analyses and rank-ordered logit regression were conducted. Results: Sixty per cent of 4302 respondents reported having unwanted medicines in their household. Medicines were primarily kept just in case they were needed again and one-third of these medicines were expired. Two-thirds of respondents disposed of medicines with the household garbage and approximately one-quarter poured medicines down the drain. Only 17.6% of respondents had heard of the RUM Project, although, once informed, 91.7% stated that they would use it. Respondents ranked the risk of unintended ingestion as the most important public health message for future social marketing campaigns. Conclusions: Respondents were largely unaware of the RUM Project, yet were willing to use it once informed. Limited awareness could lead to environmental or public health risks, and targeted information campaigns are needed. What is known about the topic?: There is a growing international evidence base on how people dispose of unwanted medicines and the negative consequences, particularly the environmental effects of inappropriate disposal. Although insight into variation in disposal methods is increasing, knowledge of how people perceive risks and awareness of inappropriate disposal methods is more limited. What does this paper add?: This study provides evidence of inappropriate medicines disposal and potential stockpiling of medicines in Australian households that could contribute to environmental and/or public health risks. It also reveals possible trends towards a higher frequency of inappropriate disposal practices in the Australian context. Insights into respondents' perceptions of associated risks and awareness of a national scheme for appropriate disposal of medicines have not previously been reported. What are the implications for practitioners?: The findings of the present study provide important insights for all health professionals as stakeholders in the quality use of medicines. It is important for those health professionals who assist consumers to manage their medicines to have strategies in place that routinely identify potential stockpiling and inform consumers about appropriate methods of medicines disposal. Although the findings of this study are specific to the Australian context, they may usefully inform policy, public health campaigns and the individual practices of health professionals and other stakeholders in promoting the quality use of medicines nationally and internationally. [ABSTRACT FROM AUTHOR]

The aim of the present case study is to illustrate the outcomes of a dedicated allied health (AH) research position within a large Queensland regional and rural health service. The secondary aim of the case study is to describe the enabling and hindering mechanisms to the success of the role. Semistructured interviews were conducted with the Executive Director of Allied Health and the current AH research fellow incumbent within the health service. A focus group was also undertaken with six stakeholders (e.g. clinicians, team leaders) who had engaged with the research position. Outcomes of the AH research fellow included clinical and service improvements, enhanced research culture and staff up-skilling, development of research infrastructure and the formation of strategic research collaborations. Despite being a sole position in a geographically expansive health service with constrained resources, key enabling mechanisms to the success of the role were identified, including strong advocacy and regular communication with the Executive. In conclusion, the case study highlights the potential value of an AH research position in building research capacity within a large non-metropolitan health service. Factors to facilitate ongoing success could include additional research and administrative funding, as well as increased use of technology and team-based research. What is known about the topic?: Dedicated research positions embedded within health care settings are a well cited strategy to increase research capacity building of allied health professionals (AHPs). However the majority of these positions are within metropolitan health settings and unique challenges exist for these roles in regional and rural areas. Few studies have described the impact of dedicated AH research positions within regional health centres or the factors which facilitate or hinder their role. What does this paper add?: Dedicated research positions within a non-metropolitan Australian health service may have a positive impact on AH clinical services, research culture, staff upskilling, research infrastructure and research collaborations. Key enabling mechanisms to support the role may include advocacy from higher level management, strong networks and communication channels. Additional research and administrative funding, the use of technology and team based research may enhance sustainability of such roles. What are the implications for practitioners?: AH research positions have potential value in building research capacity within a large non-metropolitan health service. Health managers and researchers should be aware of the unique challenges to these roles and consider mechanisms that may best enhance and sustain outcomes of the positions including: the development of infrastructure (i.e. technology, website of resources), networks, and communication strategies (i.e. regular meetings with leadership and promotion internally). [ABSTRACT FROM AUTHOR]

Objective: Understanding the effect of professional attitude on professional behaviour is conducive to the development of targeted measures to promote professionalism. The aim of the present study was to explore the effect of professional attitude on professional behaviour. Methods: Using a self-reported questionnaire, 212 physicians were surveyed using quota sampling in six tertiary hospitals in Nanchang City. The effect of professional attitude on professional behaviour was analysed through logistic regression analysis. Results: Providing necessary care regardless of a patient's ability to pay, working on quality improvement initiatives, informing patients of medical errors and reporting incompetent colleagues had significant positive effects on corresponding professional behaviour (odds ratios (95% confidence intervals) 11.06 (3.78, 32.40), 9.42 (1.93, 46.01), 4.04 (1.29, 12.63) and 5.51 (1.26, 24.08) respectively). However, attitudes towards minimising disparities in care, undergoing periodic recertification examinations and reporting medical errors did not significantly affect corresponding professional behaviour. Conclusions: Professional attitude affects professional behaviour, but such an effect varies with different professional norms. These findings imply that improving the professional attitude is useful but insufficient to promote medical professionalism. A management system conducive to the conversion of professional attitude to professional behaviour should be established. What is known about the topic?: Several studies have affirmed that Chinese physicians accept most areas of medical professionalism embodied in the Charter on Medical Professionalism. However, only a few published studies have examined the effect of professional attitude on professional behaviour. Understanding the effect of professional attitude on professional behaviour is conducive to the development of targeted measures to promote professionalism. The present study attempted to fill the current knowledge gaps. What does this paper add?: The study surveyed professional attitudes and behaviour of Chinese physicians and explored the effects of the former on the latter. The study found that professional attitude affects professional behaviour, but such an effect varies with different professional norms. The results may help establish fundamental problems in the professionalism of physicians and in measures to promote professional behaviour not only in China, but also in other countries. What are the implications for practitioners?: The implications for hospital managers and policy makers are that improving professional attitude is useful but insufficient to promote medical professionalism. A management system conducive to the conversion of professional attitude to professional behaviour should be established. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify whether the Hospital in the Home (HITH) program was taken up equitably by eligible patients in relation to their age, sex, country of birth, place of residence and primary diagnosis. Methods: This study presents results of a descriptive analysis of the administrative records of 3552 people with specific conditions who met the study criteria of potential eligibility to HITH and resided within the health district boundary. Results: Systematic differences were found for participation in HITH and in-patient care according to sex, language spoken at home and socioeconomic status based on place of residence. This suggests that people from higher socioeconomic backgrounds who speak English at home were more likely to participate in and benefit from HITH. Tailored interventions were identified as a potential way to reduce the gap in access to quality health care for women and people who speak a language other than English at home. If HITH is the optimum treatment available, then these differences could be considered potentially avoidable and unfair. Conclusion: Data analysis through an equity lens can effectively identify who is accessing health services and who is missing out. Further analysis is required to understand patient and system barriers to accessing HITH. What is known about the topic?: Advances in medical and surgical treatments and pharmaceuticals reduce the need for in-patient hospitalisation. For some conditions, home-based treatment is safer, cheaper and preferable to the patient and carers, particularly some older people who may experience deteriorating cognitive and physical functioning related to hospitalisation. It is well known that health and access to health care is not equally distributed in society. What does this paper add?: This study represents the first effort to quantitatively evaluate differences in patterns of participation in HITH related to socioeconomic and language characteristics. There are underutilised opportunities for improved participation in HITH by identifying who is not accessing programs at a comparable rate and therefore not benefitting from optimal health services. By exploring why this may be occurring at an individual and system level, we can be more informed to address these reasons and achieve better health and social outcomes. What are the implications for practitioners?: It is important to consider both consumer and service provider views in shaping current and future service models. Comprehensive assessment of support needs to participate in HITH for patients and carers, as well as communicating potential benefits in ways patients understand, can improve participation and satisfaction, reduce health costs and improve health outcomes. [ABSTRACT FROM AUTHOR]

Objective. The Australian Dental Council is responsible for the assessment of overseas-qualified dentists seeking to practice dentistry in Australia. The aim of this paper is to reflect on the Council's assessment and examination process through the experiences and perceptions of overseas-qualified dentists in Australia. Methods. Qualitative methods were used. Life stories of 49 overseas-qualified dentists from 22 nationalities were analysed to discern significant themes and patterns. We focused on their overall as well as specific experiences of various stages of the examination. The analysis was consistent with a hermeneutic phenomenological approach to social scientific research. Results. Most participants referred to 'cost' of the examination process in terms of lost income, expenses and time. The examination itself was perceived as a tough assessment process. Some participants seemed to recognise the need for a strenuous assessment due to differences in patient management systems in Australia compared with their own country. Significantly, most of the participants stressed the importance of support structures for overseas-qualified dentists involved in or planning to undertake the examination. These considerations about the examination experience were brought together in two themes: (1) 'a tough stressful examination'; and (2) 'need for support.' Conclusion. This paper highlights the importance of support structures for overseas-qualified dentists. Appropriate support (improved information on the examination process, direction for preparation and training, further counselling advice) by recognised bodies may prevent potential exploitation of overseas-qualified dentists. Avenues that have been successful in providing necessary support, such as public sector schemes, offer policy options for limited recruitment of overseas-qualified dentists in Areas of Need locations. Such policies should also be in line with the local concerns and do not reduce opportunities for Australian-qualified dentists. [ABSTRACT FROM AUTHOR]

Objective. Faced with longstanding and increasing demand for specialist out-patient appointments that was unable to be met through usual medical consultant led care, Metro North Hospital and Health Service in 2014-15 established 11 allied health primary contact out-patient models of care. Methods. The models involved six different allied health professions and nine specialist out-patient departments. Results. All the allied health models have been endorsed for continuation following demonstration of their contribution to managing demand on specialist out-patient services. Conclusion. This paper describes key features of the allied health primary contact models of care and presents preliminary data including new case throughput, effect on wait times and enablers and challenges for clinic establishment. [ABSTRACT FROM AUTHOR]

Organisational health literacy (OHL) is a relatively new concept and its role in improving population health outcomes is gaining recognition. There are several terms being used in relation to OHL but there is no consensus about the definition of OHL nor agreement on a single approach to its application within health services. This contested space continues to create discussion and debate between health literacy researchers worldwide. Increasingly, health service accreditation standards are moving towards including OHL and so services need to clearly define their roles and responsibilities in this area. Inherent in this is the need to develop and validate quantifiable measures of OHL change. This is not to say it needs a 'one-size-fits-all' approach but rather that terminology needs to be fit for purpose. This paper reviews the literature on OHL, describing and contrasting OHL terminology to assist practitioners seeking OHL information and health services clarifying their roles and responsibilities in this area. [ABSTRACT FROM AUTHOR]

Objective This paper describes the 4-year journey of Hunter and New England HealthPathways - a password-protected web-based portal designed to provide localised evidence-informed clinical and referral information to support general practice at the point of care.Methods A process evaluation was conducted in 2013, with a case study comparison performed in 2014 to assess impact of HealthPathways on patient referral and access to specialist care, followed by a review in 2016 of utilisation of the online portal to assess whether healthcare providers continued to access HealthPathways.Results Increased utilisation was correlated with an increase in the number of pathways published online. Clinical leadership and the process of developing pathways built relationships between primary care and specialist teams. Case studies indicated that a comprehensive approach to pathway implementation accompanied by service redesign resulted in higher pathway use and improved access to specialist care. Senior management support and a formal partnership between major health care providers led to strong governance of HealthPathways and the delivery of other integrated care initiatives. There was significant growth in utilisation over the 4 years, increasing to an average of 6679 sessions per month in 2016 and more general practices reported use of HealthPathways.Conclusions HealthPathways is a vehicle for building strong foundations to support system change and integrated care. The critical elements for acceptability, growth and sustainability are the strong relationships between primary care and specialist clinicians, as well as formal partnerships that are built from the processes used to develop HealthPathways. [ABSTRACT FROM AUTHOR]

Objective This paper explores how hospital complaints managers react to recommendations for systemic quality reforms by health complaints commissions in response to complaints by patients in Queensland and New South Wales. Methods Semi-structured qualitative interviews were conducted with complaints managers in 17 hospitals. Interview transcripts were then thematically analysed and data on responses to health complaint commissions was organised in relation to Valerie Braithwaite's typology of motivational postures. Results Respondents supported involvement by an independent authority where patients had serious complaints about the services they received in hospital, but wanted more negotiation with commissions on service improvement recommendations. Conclusions Hospital complaints managers mostly responded as virtuous or rational actors to the symbolic power of complaints commissions. This may be context dependent because Australian health commissions operate within a pro-reform context as a result of recent publicity around health system failures. [ABSTRACT FROM AUTHOR]

Objective Since the introduction of legislative changes in 2010, services provided by privately practising nurse practitioners (PPNPs) in Australia have been eligible for subsidisation through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS). To provide eligible services, PPNPs must collaborate formally with a medical practitioner or an entity that employs medical practitioners. This paper provides data from a national survey on these collaborative arrangements in Australia. The aim of the study was to evaluate the impact of PPNP services on patient access to care in Australia. Methods PPNPs in Australia were invited to complete an electronic survey. Quantitative data were analysed using descriptive statistics, whereas qualitative data were analysed using thematic analysis. Seventy-three surveys were completed. Results Ninety-three per cent of participants reported having a collaborative arrangement in place. Frequency of communication ranged from daily (27%) to never (1%). Participants reported that collaborative arrangements facilitate learning, patient care and offer support to PPNPs. However, for some PPNPs, organising a formal collaborative arrangement is demanding because it is dependent on the availability and willingness of medical practitioners and the open interpretation of the arrangement. Only 19% of participants believed that collaborative arrangements should be a prerequisite for PPNPs to access the MBS and PBS. Conclusion Although there are benefits to collaborative arrangements, there is also concern from PPNPs that mandating such arrangements through legislation presents a barrier to establishing PPNP services and potentially reduces patient access to care. Collaboration with medical practitioners is intrinsic to nursing practice. Thus, legislating for collaborative arrangements is unnecessary, because it makes the normal abnormal. [ABSTRACT FROM AUTHOR]

Objective To explore service availability and accessibility for people with advanced chronic obstructive pulmonary disease (COPD) and their carers and strategies for improvement, including the potential role of a COPD care co-ordinator in ensuring best-practice care in the Australian context. Methods This qualitative study used focus groups and interviews with health professionals, carers and consumers to explore gaps and restrictions in services, barriers to access and the functioning of services. Data were analysed deductively. Results Key themes arising from the data included difficulties around access to care, lack of continuity of care, poor care co-ordination, the need for active disease management as well as supportive care, and poor communication. A COPD care co-ordinator was suggested as an effective strategy for ensuring best-practice care. Conclusions People with advanced COPD often have difficulty navigating the acute, primary and community care systems to deal with the multiple services that they may require. Lack of communication between health professionals and services is frequently a significant issue. A COPD care co-ordinator, encompassing advanced nursing skills, could ensure that care is centred on the needs of the person and their carer and that they receive continuing, appropriate and accessible care as they approach the end of their life. What is known about the topic? The importance of care co-ordination as a quality care indicator in chronic disease is growing, and the care co-ordinator role as a facilitator of quality care is increasingly being recognised in the UK and US. There is currently little information in the Australian context about how a COPD care co-ordinator role could be implemented, where it could be situated and the level of skill required. What does this paper add? This paper explores the specific issues in developing a COPD care co-ordinator role and provides a detailed model of care for the introduction of care co-ordinators into the Australian setting. What are the implications for practitioners? The proposed COPD care co-ordinator role has the potential to improve quality, continuing care for people with advanced COPD. It could facilitate the linkage of multidisciplinary teams across acute, primary and community care settings and promote timely and effective communication. The role would provide a clear point of contact for all practitioners and the opportunity for nurses to develop an advanced practice role in COPD care co-ordination, combining a palliative care approach with a chronic disease management framework. [ABSTRACT FROM AUTHOR]

Introduction. To examine the factors associated with unplanned readmission among older adults with congestive heart failure (CHF) within 28 days of discharge from an index admission, within a large Australian health service. Methods. Using a comparative cohort design, a multivariate logistic regression model was used to compare readmitted patients with non-readmitted patients and identify risk factors associated with readmission. Results. Significant risk factors identified were male gender, numerous diagnoses, length of stay 3 days or longer and patients being admitted from acute, subacute or aged-care facilities. Conclusions. The high risk of patients being readmitted from acute, subacute and aged-care services requires further review as these readmissions may be avoidable. It may also be useful to develop a readmission risk screening tool so that patients at risk of readmission can be identified. What is known about this topic? Older adults with CHF are likely to experience multiple readmissions to hospital. There have been several studies conducted on hospital readmissions; however, generalising the findings is problematic due to the use of variable definitions of what constitutes a readmission. What does this paper add? This paper addresses the absence of Australian research comparing groups of older patients with CHF who are readmitted to hospital with those who are not readmitted. It also adopts one of the more frequently used definitions of readmission to aid in future comparability of research. What are the implications for practice? Further work is necessary to improve discharge planning and effectively manage chronic illnesses such as CHF in patients' homes. It may be useful to develop a readmission risk screening tool for staff of inpatient medical wards so that these at-risk patients can be identified before discharge. [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]

Objectives. To determine the preferences of multidisciplinary stroke clinicians for models of inpatient stroke unit care and perceived barriers to establishing a comprehensive stroke unit (CSU) model (acute and rehabilitation care in the same ward). Methods. Written questionnaires distributed and completed at multidisciplinary stroke unit case conferences in NSW, Australia. Results. Twenty hospitals with 22 stroke units were surveyed, 13 acute stroke units, 7 rehabilitation stroke units, 2 CSUs. Two hundred and twenty-eight respondents: 99 (43.4%) allied health, 72 (31.6%) nurses and 57 (25.0%) doctors. One hundred and fifty-one respondents (67.0%) thought CSU to be the best model. Seventy-three % of doctors and 79% of allied health preferred CSU v. 57% of nurses (P = 0.041). Of doctors, rehabilitation specialists were most likely to favour comprehensive model (84.2%) and neurologists least (57.0%). The main perceived advantages of CSU were reduced cost and improved functional outcomes; perceived disadvantages were increased workload and unwell patients unable to participate in rehabilitation. Main perceived barriers to establishing CSU were lack of space, money, staffing and time. Conclusion. Although most current stroke unit care in NSW is based on the traditional model of acute and rehabilitation components in separate wards or hospitals, the majority of multidisciplinary stroke team clinicians believe CSU is the optimum model. What is known about the topic? Stroke unit care is known to improve survival and dependency but the optimum model of care is unproven, despite some small studies suggesting that the CSU model may result in better outcomes. What does this paper add? This paper is the first to survey stroke clinicians from various disciplines and types of unit, to determine their preferences for stroke unit model. What are the implications for practitioners? A majority of clinicians expressed a preference for the CSU model, suggesting that most would be comfortable caring for patients in both acute and rehabilitation phases of stroke care if further such units are established. [ABSTRACT FROM AUTHOR]

Over the past half century, medical care has become less institutionalised, more autonomous, equitable and less costly. This has led to a shift from hospital-based delivery to community care. This paper examines the experiences of Canberra-based carers following this shift using interview data from a longitudinal qualitative study of 32 informal carers of a spouse with cancer. Cancer patients experienced poorly coordinated care. When carers observed the effects of errors and miscommunication on patients, they felt compelled to coordinate patient care. Interview data suggest that informal carers of cancer patients are relied upon to manage patient care at home and in hospitals, but are not supported in undertaking this responsibility. This implies that carers should be a far more central focus in cancer care reform strategies. What is known about the topic? Shifts in Australian models of care mean much of the care-work associated with cancer has moved from hospitals to home. Little is known about the implications of this shift on carers of cancer patients, a population at high risk of stress, depression and anxiety. What does this paper add? This study offers a rare qualitative approach to understanding the experiences of carers of spouses with cancer in Canberra-based hospitals. Their accounts suggest that cancer carers are relied on to coordinate care for their spouse on a long-term basis at home, in hospitals and across multiple medical modalities. What are the implications for practitioners? This high reliance on an informal caregiving population with a well-documented risk of stress, anxiety and depression suggests that strategic changes need to be made to support carers. As states and territories begin to implement cancer care coordinators as part of a cancer reform strategy, carers should be a central focus. [ABSTRACT FROM AUTHOR]

Objective. To evaluate factors associated with the availability of same or next day appointments and after-hours access reported by Australian general practitioners (GPs). Methods. Secondary analysis of a survey of primary care practitioners conducted by the Commonwealth Fund in 2009 in 11 countries. Analysis of factors likely to be associated with reported availability of same or next day appointments and after-hours access. Findings. Of 1016 Australian GPs, 78.8% reported that most patients in their practice had access to an appointment on the same or next day and 50% that their practice had arrangements for after-hours access. Access to same or next day care was better in practices where practitioners reported larger numbers of patients seen per GP per week and reviewed their performance against annual targets, but worse in rural areas and practices routinely reviewing outcomes data. Arrangements for after-hours care were more common among GPs who were planning to retire in the next 5 years; worked in practices with high electronic functioning information systems; and received and reviewed clinical outcome data and incentives for performance. Conclusions. Improving after-hours access requires a comprehensive approach which includes incentives, improvements to information management and organised systems of care with review of data on clinical outcomes. What is known about the topic? Access to general practice is an important priority for the health system and the subject of several reforms and initiatives over the past decade in Australia. Access to same or next day appointments and after-hours has been an increasing concern related to workforce availability, and limited access to general practice is one factor influencing the demand on hospitals, especially their emergency departments. What does this paper add? This paper reports on secondary analysis of a survey of over 1000 general practitioners in Australia. Responses to questions about access to same or next day appointments or after-hours arrangements were analysed for associations with practitioner and practice characteristics and their processes and systems of care. Access to same day appointments is particularly challenging in rural general practice but is more likely to be reported by GPs working in larger practices. Incentives, quality improvement and better information management may be important strategies to improve after-hours access. What are the implications for practitioners? Strategies to improve access to appointments and to after-hours care need to be considered as part of a comprehensive approach which includes financial incentives, strengthening information systems and quality improvement activities. [ABSTRACT FROM AUTHOR]

Background. This study examined postgraduate work after an undergraduate clinical year spent in the Rural Clinical School of Western Australia (RCSWA), compared with 6 weeks Rural Undergraduate Support and Coordination (RUSC)-funded rural experience in a 6-year undergraduate medical course. Rural background, sex and Rural Australian Medical Undergraduate Scholarship (RAMUS)-holding were taken into account. Methods. University of Western Australia undergraduate data were linked by hand with postgraduate placements to provide a comprehensive dataset on the rural exposure history of junior medical practitioners working in Western Australia between 2004 and 2007. Results. Participation in the RCSWA program was associated with significantly more postgraduate year one rural work than RUSC placement alone (OR=1.5, CI 0.97-2.38). The RCSWA workforce effect increased at postgraduate year two (OR=3.0, CI 1.6484 to 5.5935 relative to RUSC). Rural-origin practitioners who chose the RCSWA program were more likely than other rural-origin practitioners to take rural rotations in both postgraduate years. RAMUS holders' choice in relation to the RCSWA program predicted later rural work. There were no effects of sex. Conclusions. Rural initiatives, in particular the Rural Clinical School program, are associated with postgraduate rural choices. The real impact of these data rely on the translation of early postgraduate choices into long-term work commitments. What is known about the topic? Specific training of rural graduates is strongly related to subsequent rural workforce. In addition, rural educational placements affect medical students' intentions to practise rurally. Retrospective data from rural relative to urban general practitioners link rural background, rural undergraduate experience and rural postgraduate experience with rural work. What does this paper add? Much of the Australian prospective outcomes research has looked at workforce intentions of graduates, or the workforce outcomes of small graduate cohorts of Rural Clinical Schools. This paper followed nearly 500 graduates by name through to their PGY1 and PGY2 workforce decisions. As this cohort comprised 80% of three completely graduated MBBS years, these data validly represent the outcome of a medical school which is comparable to all Australian medical schools in its RUSC, Rural Clinical School and RAMUS recipients. The paper provides the first peer-reviewed outcomes data for the RAMUS scholarship program. What are the implications for practitioners? Rural supervision of medical students is an effective way to recruit new workforce. The longer students are supervised in rural settings, the better. But undergraduate programs need to be linked with postgraduate initiatives that take graduates of medical student initiatives into vocational programs able to deliver a trained rural workforce. [ABSTRACT FROM AUTHOR]

Objective. The aim of this study was to determine the patient characteristics associated with unplanned return visits, using routinely collected hospital data, to assist in developing strategies to reduce their occurrence. Methods. Emergency department data from a regional hospital were analysed using univariate and multivariate methods to determine the influence of clinical, service usage and demographic patient characteristics on unplanned return visits. Results. Around 80% of the 16000 patients attending emergency presented on only one occasion in a year. Five per cent of patients presented with an unplanned return visit. Older patients, those with minor and low urgency conditions and with non-psychotic mental health conditions, those presenting during winter and after hours were significantly more likely to present as unplanned return visits. Conclusion. Although patient characteristics associated with unplanned return visits have been identified, the reasons underpinning the unplanned return visit rate, such as patient service preference and attitudes, need to be more fully investigated. What is known about the topic? Patients who present as unplanned return visits are older and have a range of chronic and acute conditions. Some unplanned return visits occur because of limited access to other non-hospital service. What does this paper add? This paper adds to the field by providing information from a regional hospital in NSW Australia on the patient characteristics associated with unplanned return visits. It provides a basis for differentiating between other groups of frequent emergency department patients. However, the reasons behind the unplanned return visit rate need to be more fully investigated. What are the implications for practitioners? The implications of the findings of this study for policy makers, administrators and clinicians are that access to alternative services for the conditions associated with unplanned return visits need to be further investigated in the context of the role for emergency department services. [ABSTRACT FROM AUTHOR]

Objective. The objective of this paper was to evaluate breakaway technique training with neuroscience nursing staff as a measure of increased confidence and safety in managing aggression. Methods. A quasi experimental design was used in a sample of neuroscience nursing staff (n=31), participating in 2×1h breakaway technique workshops. The workshops consisted of supervised skills training in safe breakaway techniques. A pre- and postintervention-matched questionnaire measuring confidence and safety around managing aggressive patients, and exposure to and confidence in dealing with breakaways, was self administered. Results. Statistically significant increases in confidence and safety in working with aggressive patients, and confidence levels for safe breakaways were reported. Qualitative comments demonstrated a desire for ongoing skills workshops. Conclusions. This study provides early evidence of the importance of incorporating breakaway training into existing training programs which aim to minimise and manage aggression and violence in generalist settings. What is known about the topic? Workplace violence is acknowledged internationally as a major occupational problem within healthcare and is reportedly increasing. The need for extensive training programs for healthcare staff is supported in the literature. What does this paper add? This would appear to be the first evaluation of breakaway training with a population of neuroscience nursing staff. Significant increases in confidence in managing aggression can be demonstrated following brief practical skills training. What are the implications for practitioners? This study provides early evidence for incorporating breakaway training into mandatory training programs for generalist health staff. Generalist health services may consider employing certified trainers to facilitate this specific skills training. [ABSTRACT FROM AUTHOR]

Objective. The aim of the present study was to describe the Ambulance Victoria (AV) secondary telephone triage service, called the Referral Service (RS), for low-priority patients calling triple zero. This service provides alternatives to ambulance dispatch, such as doctor or nurse home visits. Methods. A descriptive epidemiological review of all the cases managed between 2009 and 2012 was conducted, using data from AV case records, the Victorian Admitted Episodes Dataset and the Australian Bureau of Statistics. Cases were reviewed for patient demographics, condition, final disposition and RS outcome. Results. In all, 107 148 cases were included in the study, accounting for 10.3% of the total calls for ambulance attendance. Median patient age was 54 years and 55% were female. Geographically based socioeconomic status was associated with the rate of calls to the RS (r = -0.72; 95% confidence interval CI -0.104, -0.049; P < 0.001). Abdominal pain and back symptoms were the most common patient problems. Although 68% of patients were referred to the emergency department, only 27.6% of the total cases were by emergency ambulance; the remainder were diverted to non-emergency ambulance or the patient'sownprivate transport. The remaining32%of cases were referred to alternative service providers or given home care advice. Conclusions. This paper describes the use of an ongoing secondary triage service, providing an effective strategy for managing emergency ambulance demand. [ABSTRACT FROM AUTHOR]

Objective: This paper describes the service distribution and models of rural outreach by specialist doctors living in metropolitan or rural locations. Methods: The present study was a national cross-sectional study of 902 specialist doctors providing 1401 rural outreach services in the Medicine in Australia: Balancing Employment and Life study, 2008. Five mutually exclusive models of rural outreach were studied. Results: Nearly half of the outreach services (585/1401; 42%) were provided to outer regional or remote locations, most (58%) by metropolitan specialists. The most common model of outreach was drive-in, drive-out (379/902; 42%). In comparison, metropolitan-based specialists were less likely to provide hub-and-spoke models of service (odd ratio (OR) 0.31; 95% confidence interval (CI) 0.21-0.46) and more likely to provide fly-in, fly-out models of service (OR 4.15; 95% CI 2.32-7.42). The distance travelled by metropolitan specialists was not affected by working in the public or private sector. However, rural-based specialists were more likely to provide services to nearby towns if they worked privately. Conclusions: Service distribution and models of outreach vary according to where specialists live as well as the practice sector of rural specialists. Multilevel policy and planning is needed to manage the risks and benefits of different service patterns by metropolitan and rural specialists so as to promote integrated and accessible services. [ABSTRACT FROM AUTHOR]

Objective. To date, there are few data on pharmacy-specific placement programs and their impact on students' work after graduation. The present study evaluated an innovative rural pharmacy placement program targeted at influencing students to work and live in rural areas after graduation. A secondary aim of the study was to explore the students' intentions to come back and practice in rural areas as a result of their involvement in the rural pharmacy program. Methods. A questionnaire was distributed, by hand, to a total of 58 third and fourth (final) year pharmacy students undertaking their rural placement in the Gippsland region, in rural Victoria in 2011 and 2012. Results. Fifty-seven responses were returned (response rate = 98%). Students stated that understanding pharmacy practice from a rural perspective, visits to rural health professionals and sites and the attitude of their preceptors were essential to their satisfaction with their rural placements. A significant number of students (72%) intend to seek employment in rural areas if opportunities arise as a result of their increased rural awareness. The key components for a successful rural placement program were described by the surveyed students as social awareness, recognising job opportunities and interprofessional learning. Conclusion. The evaluation of the rural placement program revealed that students valued their visits to rural sites and their interaction with other rural health professionals the most. What is known about the topic? Rural undergraduate student programs have been initiated as a result of several Australian government strategies to address shortages in rural health workforce. Subsequently, various rural placement programs have been integral parts of several disciplines, including medicine, dentistry, nursing, occupational therapy and pharmacy among others. To date, there are few data on pharmacy-specific placement programs and their impact on students' work after graduation What does this paper add? The rural pharmacy program is important in influencing students' perceptions and interest in a career in rural areas. The key components for a successful rural placement program were described by the surveyed students as social awareness, recognising job opportunities and interprofessional learning. What are the implications for practitioners? Interprofessional learning and collaboration are inevitable due to the shortage of health professionals and the move towards holistic management of patients in healthcare settings. The development of an interprofessional rural education that combines rural medical and pharmacy students together highlights the importance of an interprofessional approach to preparing students to work in rural areas. [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]

Objectives. The Baume Report (1994) on Australia's surgical workforce had the potential to impact upon the health and educational sectors. This paper analyses the recommendations of this report and their impact at the time and 15 years later (2009). Methods. A questionnaire-based study was performed with the 18 senior Fellows and the Royal Australasian College of Surgeons (RACS) solicitor who had been instrumental in facilitating responses to the review. Results. The 19 respondents were asked to evaluate 22 areas from the Baume Report. The most highly ranked areas identified as being reasonable in 1994 were: additional funding being made available for more training positions, identifying workforce deficits, moving towards compulsory continuing professional development and having evidence of competence before introducing new technology. In 2009, the most highly ranked areas were: funding for more training positions; compulsory continuing professional development, involving the profession in improvements and broadening the training environment beyond public hospitals. Areas considered to be substantially addressed were: the selection process and encouragement of diversity, workforce numbers and deficits, confirming the educational merit of the training program and the role of professional colleges. Conclusions. The Baume Report highlighted many issues including workforce planning, the role of professional organisations in society and the complex interface between health and education. Issues of ongoing standards through a surgical career, access for patients to surgical services, funding for more training posts to provide the appropriate workforce level and distribution, and the assessment and introduction of technology remain priorities. Time has not diminished the relevance of these issues. [ABSTRACT FROM AUTHOR]

Objective. This paper reports on a project to examine the expectations of senior nurses regarding graduate roles of registered and enrolled nurses educated in Victoria, Australia. Methods. Participants completed an online survey to indicate whether predetermined competencies were in the roles of graduate enrolled or registered nurses or not in the role of either nurse. Chi-squared analysis was used to identify differences between participant groups. Results. Participants expressed variations in role expectations for the different level of graduate nurse. Although basic nursing care was undertaken by both graduate enrolled and registered nurses, no specific role was identified for enrolled nurses. Differences were found in the opinions of senior nurses over the roles of graduate nurses, demonstrating considerable variation in expectations. Management, education and research roles were not identified as the role of either nurse on graduation. Differences were found in the expectations of the different senior nurse groups regarding the roles of the enrolled nurse, particularly in the new skills taught in the enrolled nurse diploma program. Conclusions. Confusion exists regarding the roles of both types of nurse on graduation. Further research across Australia is required to clarify the roles of the different level of nurse in different practice contexts. [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]

Objectives. This paper aims to examine whether an adaptation of the International Classification of Disease (ICD) coding system can be applied retrospectively to final paramedic assessment data in an ambulance dataset with a view to developing more fine-grained, clinically relevant case definitions than are available through point-of-call data. Methods. Over 1.2 million case records were extracted from the Ambulance Victoria data warehouse. Data fields included dispatch code, cause (CN) and final primary assessment (FPA). Each FPA was converted to an ICD-10-AM code using word matching or best fit. ICD-10-AM codes were then converted into Major Diagnostic Categories (MDC). CN was aligned with the ICD-10-AM codes for external cause of morbidity and mortality. Results. The most accurate results were obtained when ICD-10-AM codes were assigned using information from both FPA and CN. Comparison of cases coded as unconscious at point-of-call with the associated paramedic assessment highlighted the extra clinical detail obtained when paramedic assessment data are used. Conclusions. Ambulance paramedic assessment data can be aligned with ICD-10-AM and MDC with relative ease, allowing retrospective coding of large datasets. Coding of ambulance data using ICD-10-AM allows for comparison of not only ambulance service users but also with other population groups. [ABSTRACT FROM AUTHOR]

Objective. Allied health (AH) includes many diverse professions, each with a unique contribution to healthcare, making it possible to consider these professions as person oriented (PO) or technique oriented (TO). This paper explored the personality traits of AH professionals from the perspective of both the PO or TO orientation and the individual professions. Methods. AH professionals (n = 562) provided demographic data and completed the Temperament and Character Inventory. Examination of the literature and a consultation process resulted in nine professions classified as PO and 10 classified as TO. Multivariate analyses compared levels of personality traits and demographic variables between the PO (n = 492) and TO (n = 70) groups, and the professions within the groups. Results. Professionals in the PO group showed significantly higher levels of traits that emphasise person orientation attributes, such as being sociable, empathic and cooperative, compared with AH professionals in professions with an emphasis on TO. Conclusions. Trends in personality traits among AH professionals were congruent with the PO and TO aspects of their chosen profession. This supports the usefulness of the PO and TO concepts in describing AH professions and may provide new clues for policy aiming to enhance job satisfaction, retention and career development. [ABSTRACT FROM AUTHOR]

Objective. To describe the development of a hospital travel plan and report baseline findings. Methods. The development of a travel plan involved an assessment of organisational barriers and enablers to travel planning, auditing of the transport to and physical environment of the hospital, a staff survey, analysis of distances staff travel to work and interviews with hospital managers. Results. There were no significant organisational impediments to, and consistent managerial support for a travel plan. The staff survey response rate was similar to response rates in workplace surveys delivered mostly online via all staff emails (n = 804, 25%). The majority (83%) of respondents drove to work on most days during the week of the survey, and the majority of drivers (58%) said they were not trying to reduce their car use and not thinking of doing so. Half (47%) of all hospital staff (n = 3222) lived within 10 km and 25% lived within 5 km. People living 5-10km from the hospital were more likely to be active travellers than were those living less than 5 km from the hospital (AOR 2.7, 95% (CI): 1.6-4.5), as were male than female staff (AOR 1.7, 95% CI: 1.1-2.9). Conclusions. The process and baseline findings described in this paper are a useful reference for Australian hospitals developing travel plans. [ABSTRACT FROM AUTHOR]

Objective. This study of equity and access characterises admissions for coronary, cerebrovascular and peripheral arterial disease by hospital type (rural, tertiary and non-tertiary metropolitan) in a representative Australian population. Methods. We conducted a descriptive analysis using data linkage of all residents aged 35-84 years hospitalised in Western Australia with a primary diagnosis for an atherothrombotic event in 2007. We compared sociodemographic and clinical features by atherothrombotic territory and hospital type. Results. There were 11 670 index admissions for atherothrombotic disease in 2007 of which 46% were in tertiary hospitals, 41% were in non-tertiary metropolitan hospitals and 13% were in rural hospitals. Coronary heart disease comprised 72% of admissions, followed by cerebrovascular disease (19%) and peripheral arterial disease (9%). Comparisons of socioeconomic disadvantage reveal that for those admitted to rural hospitals, more than one-third were in the most disadvantaged quintile, compared with one-fifth to any metropolitan hospital. Conclusions. Significant differences in demographic characteristics were evident between Western Australian tertiary and non-tertiary hospitals for patients hospitalised for atherothrombotic disease. Notably, the differences among tertiary, non-tertiary metropolitan and rural hospitals were related to socioeconomic disadvantage. This has implications for atherothrombotic healthcare provision and the generalisation of research findings from studies conducted exclusively in the tertiary metropolitan hospitals. What is known about the topic? Equity and access to hospital care for atherothrombotic disease in a geographically diverse population is poorly characterised. National data show that both fatal and non-fatal coronary heart disease and non-fatal stroke hospitalisations increase with remoteness. Fatal in-hospital stroke is greatest in major cities, whereas peripheral arterial disease hospitalisations are greatest in the inner and outer regional areas. What does this paper add? This study demonstrates that around 13% of atherothrombotic events were treated in rural hospitals with in-hospital case fatality higher than in tertiary and non-tertiary metropolitan hospitals. A greater proportion of atherothrombotic disease cases treated in rural hospitals were in the most disadvantaged Socioeconomic Indices For Area group. What are the implications for practitioners? It is important to consider differences in disadvantage when generalising results of studies generated from tertiary hospital data to non-tertiary metropolitan and rural patients. [ABSTRACT FROM AUTHOR]

Introduction. Australian medical speciality colleges have adapted and integrated the CanMEDS Physician Competency Framework into their training programs. The role as manager is one of the competencies and is presently thought to receive little attention during training. The objective of our study was to investigate the perceptions of Australian junior doctors regarding their management skills and their perceived need for management education. Methods. In November and December 2011, 1376 junior doctors from eight Victorian metropolitan health services were invited via email to participate in this study. Participating junior doctors received a questionnaire regarding their self- perceived management skills and knowledge and a medical management training needs assessment. Results. The response rate of one of the health centres was too low (6%) and therefore insufficient for credible conclusions to be drawn. Of the other health services, 194 (16%) out of 1213 junior doctors responded to the survey. Overall, the junior doctors rated their perceived competency on a 1-5 Likert scale as moderate (mean 3.45; s.d. 0.42). Of the 194 residents who responded, 71.3% (n = 139) reported a need for management training. Discussion. The junior doctors of Victoria, Australia perceived their knowledge on medical management as moderate. The results of this study showed that there is a perceived need among junior doctors for more management training. This need seems to confirm that management skills are thought to be valuable in medical practice. Our study also suggests that before the development of specific interventions, there is a need for a gap analysis between the perceived and actual management skills desired in medical residents. The attention paid to the role 'as manager' should therefore be embedded in training of all junior doctors. What is known about the topic? The CanMEDS 2005 Framework describes the seven key competencies physicians should possess to meet the needs of patients and society, and was developed by The Royal College of Physicians and Surgeons of Canada. One of these competencies is the role as manager. Published studies have shown that medical residents have a need for education in healthcare management in basic and postgraduate medical training. What does this paper add? In this study we discovered that junior doctors in Victorian metropolitan health services have a moderate perception of their competencies as managers. Previous management experience influenced the perceived competence in a positive way. What are the implications for practitioners? We believe that it is necessary that junior doctors continue to build on existing opportunities to develop their management skills. In order to achieve this, awareness of the importance of management competencies and the possibilities to obtain management experience must be raised among junior doctors. Furthermore, they need to be given the opportunity to obtain experience. [ABSTRACT FROM AUTHOR]

Introduction. In July 2011, 29 residential aged care facilities (RACF) located in the Grampians rural region, Victoria, participated in the Grampians healthcare-associated infection (HAI) and antimicrobial use point prevalence study. Methods. On a single day, trained infection control consultants collected data using two surveys. The RACF survey enabled collection of information (e.g. occupancy levels) about each RACF and its residents. The resident survey was completed for eligible high-level care residents who presented with signs and symptoms of a HAI and/or were prescribed an antimicrobial. A literature review was undertaken so comparisons could be made against similar studies. Results. The Grampians prevalence of residents presenting with ≥1 HAI (3.8%) was higher than the pooled prevalence (2.3%) for four international studies (P = 0.01). The Grampians prevalence of residents prescribed ≥1 antimicrobial (8.3%) was higher than the pooled prevalence (5.8%) for eight international studies (P = 0.009). Conclusion. The prevalence of the Grampians residents presenting with ≥1 HAI and residents prescribed ≥1 antimicrobial were both observed to be significantly higher than pooled data from similar international studies. What is known about this topic? RACF residents are vulnerable to HAI for a variety of reasons (e.g. comorbidities and functional disabilities). Inappropriate antimicrobial use for these HAI may lead to the emergence of antimicrobial resistance, adverse drug reactions and excessive costs. The literature does not extensively detail surveillance programs that measure HAI or antimicrobial use in Australian RACF. What does this paper add? In a sample of Australian RACF, the Grampians point prevalence study established a baseline prevalence of HAI and antimicrobial use. The rates calculated were shown to be significantly high when compared with similar studies. What are the implications for practitioners? Quality improvement initiatives that might decrease the prevalence of HAI and antimicrobial use in Australian RACF should be investigated and supported by key stakeholders. [ABSTRACT FROM AUTHOR]

Objective. To understand what impact hospital inpatient occupancy levels have on patient throughput by analysing one hospital's occupancy levels and the rate of patient discharge. Methods. A four-stage model was fit to hospital admission and separation data and used to analyse the per-capita separation rate according to the patient load and the impact of hospital over-census actions. Results. Per-capita separation rates are significantly higher on days when the hospital declares an over-census due to emergency department crowding. Per-capita separation rates are also higher or lower on days with 8-10% higher or lower patient loads, respectively, but the response is not nearly as strong as the response to an over-census declaration, and is limited to patients with an elapsed stay of 10 days or more. Within the medical division there is an increase in per-capita separation rates on over-census days, but no significant difference in per-capita release rates for different patient loads. Within the surgical division there is no significant difference in per-capita separation rates on over-census days compared with other days, but the patient load does make a significant difference. Conclusion. Staff do discharge a greater proportion of long-stay patients when the hospital is experiencing high demand and a lower proportion when occupancy is low, but the reasons driving those changes remains unclear. What is known about the topic? The evidence regarding safe and efficient levels of hospital occupancy is limited. There is minimal empirical evidence that confirms the relationship between occupancy and discharge rates. What does the paper add? Per-capita separation rates increase strongly on over-census days. The hospital increases per-capita separation rates on days of high occupancy and reduces it on days of low occupancy, mostly for long-stay patients with over 10 days of elapsed stay. The response to high occupancy is not as strong as the response to over-census. The medical division responds strongly to the over-census and the surgical division does not. The surgical division responds more to occupancy levels within its own division than does the medical division. What are the implications for practitioners? The implementation of over-census-type responses to periods of high occupancy may result in increased per-capita separation rate. Using mathematical analysis to understand patient load on per capita separation is important to create a better understanding of health service delivery, thereby aiding hospital managers, and has the potential to guide system improvement. The clinical drivers for these changes and the service design implications require further investigation. [ABSTRACT FROM AUTHOR]

Objective. The present study was designed to further understand the psychosocial drivers of crowds impacting on the demand for healthcare. This involved analysing different spectator crowds for medical usage at mass gatherings; more specifically, did different football team spectators (of the Australian Football League) generate different medical usage rates. Methods. In total, 317 games were analysed from 10 venues over 2 years. Data were analysed by the ANOVA and Pearson correlation tests. Results. Spectators who supported different football teams generated statistically significant differences in patient presentation rates (PPR) (F15, 618 = 1.998, P = 0.014). The present study confirmed previous findings that there is a positive correlation between the crowd size and PPR at mass gatherings but found a negative correlation between density and PPR (r = -0.206, n = 317, P <; 0.0005). Conclusions. The present study has attempted to scientifically explore psychosocial elements of crowd behaviour as a driver of demand for emergency medical care. In measuring demand for emergency medical services there is a need to develop a more sophisticated understanding of a variety of drivers in addition to traditional metrics such as temperature, crowd size and other physical elements. In this study we saw that spectators who supported different football teams generated statistically significant differences in PPR. What is known about this topic? Understanding the drivers of emergency medical care is most important in the mass gathering setting. There has been minimal analysis of psychological 'crowd' variables. What does this paper add? This study explores the psychosocial impact of supporting a different team on the PPR of spectators at Australian Football League matches. The value of collecting and analysing these types of data sets is to support more balanced planning, better decision support and knowledge management, and more effective emergency medical demand management. What are the implications for practitioners? This information further expands the body of evidence being created to understand the drivers of emergency medical demand and usage. In addition, it supports the planning and management of emergency medical and health-related requirements by increasing our understanding of the effect of elements of 'crowd' that impact on medical usage and emergency healthcare. [ABSTRACT FROM AUTHOR]

Background Falls are the leading cause of injury in older people. Rehabilitation services can assist individuals to improve mobility and function after sustaining a fall-related injury. However, the true effect of fall-related injury resulting in hospitalisation is often underestimated because of failure to consider sub-acute and non-acute care provided following the acute hospitalisation episode. Aim This study aims to describe the sub-acute and non-acute health service use of individuals hospitalised in New South Wales (NSW), Australia for a fall-related injury during 2000-01 to 2008-09, to examine the burden of fall-related inpatient rehabilitation hospital admissions from 1998-99 to 2010-11 and to estimate future demand for fall-related inpatient rehabilitation admissions in NSW to 2020. Method Retrospective review of sub-acute and non-acute records linked to hospital admission records during 2001-02 to 2008-09 in NSW. Analysis of temporal trends from 1998-99 to 2010-11 and projections to 2020 for rehabilitation-related (ICD-10-AM: Z47, Z48, Z50, Z75.1) inpatient hospital admissions. Results There were 4317 individuals with a fall-related injury admitted to hospital and subsequently admitted for sub-acute and non-acute care; 84% of these were aged 65+ years; 70.4% were female and 27.2% had femur fractures. For the rehabilitation-related admissions, total mean functional independence measure (FIM) scores improved significantly (from 78.4 to 94.6; P <; 0.0001) between admission and discharge. Fall-related inpatient rehabilitation episodes increased by 9.1% each year between 1998 and 2011 for individuals aged 65 years and older and are projected to rise to 50 000 admissions annually by 2020. Conclusion This is the first study to provide an epidemiological profile of individuals using sub-acute and non-acute care in NSW using linked data. Improvements in data validity and reliability would enhance the quality of the sub-acute and non-acute care data and its ability to be used to inform resource use in this sector. The examination of temporal trends using only the inpatient hospital admissions provides a guide for resource implications for inpatient rehabilitation services. What is known about this topic? Fall-related injuries that result in inpatient hospital admissions are increasing in Australia. However, the extent of the effect of fall-related injuries in the sub-acute and non-acute sector remains unknown, due to data limitations. What does this paper add? Provides the first epidemiological profile of individuals who fall and go on to use sub-acute and non-acute care in NSW using linked data. It highlights where improvements in data quality in the sub-acute and non-acute care data could be made to improve their usefulness to inform resource use in this sector. What are the implications for clinicians? Fall injury prevention and healthy ageing strategies for older individuals remain a priority for clinicians. The current and projected future resource implications for inpatient rehabilitation and follow-up services provide an indication for clinicians of future demand in this area as the population ages. However, data quality needs to improve to provide clinicians with strongly relevant guidance to inform clinical practice. [ABSTRACT FROM AUTHOR]

Introduction. The Australian federal government is developing a policy response to chronic disease in Australia. The Serious and Continuing Illness Policy and Practice Study examined the experience of individuals with chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) or type 2 diabetes mellitus (diabetes) in the Australian Capital Territory (ACT) and Western Sydney. This paper describes the disease-specific experiences of people interviewed. Methods. We conducted semi-structured interviews with 40 individuals aged 45-85 years with CHF, COPD or diabetes in 2008. Interviews were recorded and transcribed. Qualitative content analysis was performed, assisted by QSR Nvivo 8 qualitative data software. Results. Participants with CHF (n = 9) came to terms with the prospect of unpredictable sudden death. Participants with COPD (n = 15) were angry about limitations it imposed on their lives. Participants with diabetes (n = 16) experienced a steep learning curve in self-management of their condition surrounded by high levels of uncertainty. Conclusion. Although people with chronic illness share many experiences, a person's overall experience of living with chronic illness is significantly shaped by the nature of their specific dominant disease. Policies for patient-centred care must take account of both generic and disease-specific elements. [ABSTRACT FROM AUTHOR]

Objective. In Australia, 25% of international medical graduates (IMGs) make up the medical workforce. Concern is expressed in the literature about the lack of awareness and knowledge of issues that impinge on IMGs' education. Although there is literature alluding to difficulties IMGs face with undertaking the Australian Medical Council (AMC) examination, there is little research detailing this experience. We therefore explored IMGs' reflections on facilitators and barriers in undertaking the AMC examination. Methods. After ethics approval, in-depth telephone interviews were conducted with 30 IMGs selected from a hospital in Queensland. Data were coded and analysed using thematic analysis principles. Results. Two facilitating themes were identified: ability to sit for the first part of the examination in country of origin; and having access to resources such as bridging courses and study groups. Three themes represented barriers: not understanding procedural steps; financial issues; and lack of information on examination content and standards. Conclusion. The themes provide new insights and add depth to existing literature that can be used to improve procedural processes and education for IMGs towards successful outcomes in the AMC examination. What is known about the topic? There is concern expressed in the literature about the lack of awareness and knowledge of issues that impinge on IMGs education. The Australian work that is available only depicts educational experience of fellowships or education and training strategies after IMGs have passed their AMC examination. What does this paper add? The findings indicate that the process of sitting for the AMC examination is perceived as one of the major difficulties associated with entering and integrating into the Australian health system. The findings indicate a range of practical, financial and resource problems faced by IMGs attempting to sit for the AMC examination. What are the implications for practitioners? The detailed accounts from IMGs about their experience with undertaking the AMC examination will provide up-skilling program coordinators with the information they need to better assist IMGs to prepare for the examination. The provision of appropriate medical training and educational support will contribute to more effective integration of IMGs into the healthcare system. [ABSTRACT FROM AUTHOR]

Objective. To ascertain the improvements in length of stay and discharge rates following the opening of an acute medical unit (AMU). Methods. Retrospective cohort study of all patients admitted under general medicine from June-November 2008. Main outcome measures were length of stay in hospital and in the emergency department (ED). Results. The length of time spent in the emergency department for those admitted to the AMU was significantly shorter than those admitted directly to a medical ward (6.83h v. 9.40h, P<0.0001). A trend towards shorter hospital length of stay continued after the AMU opened compared with the same period in the previous year (5.15 days (2.49, 11.57 CI) v. 5.66 days (2.76, 11.52 CI)). However, the number of ward transfers for a patient and the need to wait for a nursing home bed or public rehabilitation affected length of stay much more than the AMU. Conclusion. An AMU was successful in decreasing ED length of stay and contributed to decreasing hospital length of stay. However, we suggest that local context is crucially important in tailoring an AMU to obtain maximal benefit, and that AMUs are not a 'one size fits all' solution. What is known about the topic? Acute Medical Units were pioneered in the UK and have been shown to decrease length of stay with no increase in adverse events. As a result, they have been enthusiastically adopted in Australia. However, most studies have been single point 'before/after' designs looking at all medical patients, and there has been little consideration of the context in which AMUs operate and how this might affect their performance. What does this paper add? We consider length of stay trends over many years and separate single organ disease from multi-system disease patients, in order to ensure that gains are not simply a result of selective entry of healthier patients into AMUs. We also show that the effect of an AMU is small compared with other systemic issues, such as waiting for nursing home placement and the number of transfers of care. What are the implications for practitioners? Although there may be gains in terms of length of stay in the emergency department, those considering the establishment of an AMU need to consider other factors that may mitigate the improvements in hospital length of stay, such as the roadblocks to discharge, the organisation of allied health staff, and the number of transfers of care. [ABSTRACT FROM AUTHOR]