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Objective The provision of medicines through state public hospitals is comparatively restrictive compared with the federally funded Pharmaceutical Benefits Scheme (PBS). Individual states are progressively moving towards statewide medicines formularies. Although a statewide formulary has existed in Queensland for some time. The effects of hospital formularies on medicines utilisation and policy in Australia has not been quantified. Thus, the aim of the present study was to quantify the effects of the Queensland Health List of Approved Medicines (LAM) on medicines utilisation in Queensland at a state and PBS-purchasing level and describe the implications for medicines policy. Methods This study used a quasi-experimental design with an interrupted time series (with control for PBS) examining utilisation effects of medicines within the therapeutic classes of proton pump inhibitors and non-vitamin K oral anticoagulants with LAM listing or delisting. Results The LAM was demonstrated to be highly effective at controlling utilisation within Queensland Health purchasing. Effects on PBS utilisation were evident, resulting in increases in generic utilisation (where available) and associated reduced total costs both within Queensland Health and to the PBS. The full benefit is likely underestimated due to limitations in the PBS datasets. Conclusion The LAM is a highly effective state medicines policy tool with demonstrable effects on PBS utilisation. With increased use of statewide medicines formularies, this will be an increasingly relevant aspect of Australia's overall medicines policy. What is known about the topic? State medicines policy is comparatively restrictive compared with the federal PBS. Most Australian states have, or are developing, statewide medicines formularies. What does this paper add? By examining several classes of medicines, a substantial quantitative effect of the Queensland state formulary on both state and PBS medicines utilisation can be demonstrated. Increased use of generic medicines and reduced costs are seen. What are the implications for practitioners? With increased use of state medicines formularies, state medicines formularies will become increasingly relevant to medicines policy makers and advocates at both the state and federal level.

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

Objective This study examined Gold Coast staff and patient experiences with the rapid expansion of a virtual model of chronic disease management during the COVID-19 pandemic. Methods The study undertook a survey of enrolled patients (n=24) and focus groups with clinical and administrative staff (n=44) delivering chronic disease programs at Gold Coast Health in Queensland. The study also examined routinely collected activity data for the chronic disease programs before COVID (January-February 2020) and for the first 3 months of the COVID-19 response (March-May 2020). Results Chronic disease programs continued to provide similar numbers of appointments over the COVID-19 response period, but there was a marked increase in the proportion of appointments that were delivered virtually, either by telephone or video conference. Most patients were satisfied with their virtual care experiences and felt that their health care needs were met. Conclusions The COVID-19 response provided an opportunity to learn and further develop models of virtual care. Staff and patients were generally supportive of continuing to include virtual appointments in the future. Ongoing concerns were predominantly around the support available to patients and staff to ensure they are trained and equipped to manage the technology and new mode of communicating. What is known about the topic? Emerging evidence suggests that virtual models of health care delivery, such as telephone and video consultations and remote patient monitoring, can be safe and cost-effective alternatives to traditional face-to-face chronic disease management programs. Virtual care is associated with equal or improved clinical outcomes, as well as efficiency improvements, such as reduced failure to attend rates. What does this paper add? The increasing burden of chronic disease across Australia, as well as the need to minimise the risk of vulnerable patient groups attending in-hospital appointments where it is safe and appropriate to do so, means that expanding the delivery of virtual chronic disease management will become increasingly necessary. The results of this study provide an opportunity to learn from a rapid rollout of virtual care for these staff and patient groups and will help inform advances in this area. What are the implications for practitioners? Existing evidence, demographic pressures and the COVID-19 pandemic response all point to virtual care as a viable and safe alternative to traditional models of chronic disease management. The lessons presented here provide more detailed guidance on the support that staff and patients require to ensure virtual care is a seamless and safe alternative or adjunct to traditional chronic disease management programs.

Objective The aim of this study was to report on the rates of obstetric interventions within each hospital jurisdiction in the state of Queensland, Australia. Methods This project used a whole-of-population linked dataset that included the health and cost data of all mothers who gave birth in Queensland, Australia, between 2012 and 2015 (n=186789), plus their babies (n=189909). Adjusted and unadjusted rates of obstetric interventions and non-instrumental vaginal delivery were reported within each hospital jurisdiction in Queensland. Results High rates of obstetric intervention exist in both the private and public sectors, with higher rates demonstrated in the private than public sector. Within the public sector, there is substantial variation in rates of intervention between hospital and health service jurisdictions after adjusting for confounding variables that influence the need for obstetric intervention. Conclusions Due to the high rates of obstetric interventions statewide, a deeper understanding is needed of what factors may be driving these high rates at the health service level, with a focus on the clinical necessity of the provision of Caesarean sections. What is known about the topic? Variation in clinical practice exists in many health disciplines, including obstetric care. Variation in obstetric practice exists between subpopulation groups and between states and territories in Australia. What does this paper add? What we know from this microlevel analysis of obstetric intervention provision within the Australian population is that the provision of obstetric intervention varies substantially between public sector hospital and health services and that this variation is not wholly attributable to clinical or demographic factors of mothers. What are the implications for practitioners? Individual health service providers need to examine the factors that may be driving high rates of Caesarean sections within their institution, with a focus on the clinical necessity of Caesarean section.

Objective To determine maternal access to continuity of midwifery care in public maternity hospitals across the state of Queensland, Australia. Methods Maternal access to continuity of midwifery care in Queensland was modelled by considering the proportion of midwives publicly employed to provide continuity of midwifery care alongside 2017 birth data for Queensland Hospital and Health Services. The model assumed an average caseload per full-time equivalent midwife working in continuity of care with 35 women per annum, based on state Nursing and Midwifery Award conditions. Hospitals were grouped into five clusters using standard Australian hospital classifications. Results Twenty-seven facilities (out of 39, 69%) across all 15 hospital and health services in Queensland providing a maternity service offered continuity of midwifery care in 2017 (birthing onsite). Modelling applying the assumed caseload of 35 women per full-time equivalent midwife found wide variations in the percentage of women able to access continuity of midwifery care, with access available for an estimated 18% of childbearing women across the state. Hospital classifications with higher clinical services capability and birth volume did not equate with higher access to continuity of midwifery care in metropolitan areas. Regional health services with level 3 district hospitals assisting with <500 births showed higher levels of access, potentially due to additional challenges to meet local population needs to those of a metropolitan service. Access to full continuity of midwifery care in level 3 remote hospitals (<500 births) was artificially inflated due to planned pre-labour transfers for women requiring specialised intrapartum care and women who planned to birth at other hospitals. Conclusions Despite strong evidence that continuity of midwifery care offers optimal care for women and their babies, there was significant variation in implementation and scale-up of these models across hospital jurisdictions. What is known about the topic? Access to continuity of midwifery care for pregnant women within the public health system varies widely; however, access variation among different hospital classification groups in Australian states and territories has not been systematically mapped. What does this paper add? This paper identified differential access to continuity of midwifery care among hospital classifications grouped for clinical services capability and birth volume in one state, Queensland. It shows that higher clinical services capability and birth volume did not equate with higher access to continuity of midwifery care in metropolitan areas. What are the implications for practitioners Scaling up continuity of midwifery care among all hospital classification groups in Queensland remains an important public health strategy to address equitable service access.

Objective To explore measures of potentially avoidable general practitioner (PAGP)-type presentations to the emergency department (ED) of a large regional hospital in northern Queensland. Methods Linkage of an ED administrative dataset to a face-to-face patient survey of local residents (n=1000); calculation of Australian Institute of Health and Welfare (AIHW) and Australasian College of Emergency Medicine (ACEM) measures of PAGP-type presentations to the ED; and exploration of these measures with patient-perspective linked data. Results PAGP-type presenters to the ED were younger in age (median age in years: total cohort: 49; AIHW 38, P<0.001; ACEM 36, P<0.001); with the odds of having a chronic condition being less likely for AIHW PAGP-type presenters than other ED presenters (OR (95% CI) 0.54 (0.38-0.77): P=0.001)) after adjustment for age. PAGP-type presenters nominated reasons of convenience rather than urgency as their rationale for attending the ED, irrespective of measure. The number of PAGP-type presentations to the ED identified by the AIHW measure was more than three-fold higher than the ACEM measure (AIHW: n=227; ACEM: n=67). Influencing factors include the low proportion of ED attendees who had a medical consultation time of <1h at this hospital site (1-month survey period: 17.8%); and differences between the patient self-report and ED administrative record for 'self-referral to the ED' (Self-referred: Survey 71% vs EDIS 93%, P<0.001). Conclusions Identification of PAGP-type presentations to the ED could be enhanced with improvements to the quality of administrative processes when recording patient 'self-referral to the ED', along with further consideration of hospital site variation for the length of medical consultation time. What is known about the topic? PAGP-type presentations to the ED are an Australian National Healthcare Agreement progress indicator. Methods of measuring this indicator have been under review since 2012 and debate remains on how to accurately determine the measure. What does this paper add? By using patient perspective-linked data to explore different measures of PAGP-type presentations to EDs, this paper identifies issues with measure elements and suggests ways to improve these measures. What are the implications for practitioners? Measure elements of patient 'self-referral to the ED' and 'medical consultation time' require further consideration if they are to be used to measure PAGP-type presentations to the ED.

Objective This study examined whether the management competency framework for health service managers developed in the Victorian healthcare context is applicable to managers in other Australian states. Methods An online questionnaire survey of senior and middle-level health service managers in both community health services and hospitals was conducted in New South Wales and Queensland. Results The study confirmed that the essential tasks for senior and middle-level managers are consistent across health and social care sectors, as well as states. Core competencies for health services managers identified in the Victorian healthcare context are relevant to other Australian states. In addition, two additional competencies were incorporated into the framework. Conclusion The Management Competency Assessment Program competency framework summarises six competencies and associated behaviours that may be useful for guiding performance management and the education and training development of health service managers in Australia. What is known about the topic? The evidence suggests that competency-based approaches can enhance performance and talent management, and inform education and training needs, yet there has been no validated competency framework for Australian health service managers. What does the paper add? This paper explains the process of the finalisation of the first management competency framework for guiding the identification of the training and development needs of Australian health service managers and the management of their performance. What are the implications for practice? The Management Competency Assessment Program competency framework can guide the development of the health service management workforce in three Australian states, and may be applicable to other jurisdictions. Further studies are required in the remaining jurisdictions to improve the external validity of the framework.

Objective The aim of this study was to explore management understanding of the lived experience required for designated lived experience or peer roles within mental health. Method This qualitative study used semi-structured interviews and one focus group with 29 participants employed in diverse management roles from the public and not-for-profit health and community sector in Queensland, Australia. Results The findings indicate a lack of consensus in defining 'lived experience', including what lived experience is required to be eligible for designated roles. Although some participants were clear on what designated roles added to the workforce, uncertainty and attempts to avoid stigma led to some participants questioning the need for designated roles. Conclusion This study suggests the ongoing expansion of the lived experience workforce is affected by challenges in defining 'lived experience' as a requirement for designated roles and fears regarding stigmatised identities. What is known about the topic? In the mental health sector, opportunities and challenges exist in attempting to effectively incorporate the emerging lived experience or peer workforce. Research has highlighted the need for support from senior management, the need for role clarity and the risk of 'othering' for the lived experience workforce. What does this paper add? This paper responds to the gap in existing research on the experiences of management in defining and articulating their understanding of lived experience and potential impact of uncertainty and inconsistency in understanding for the lived experience workforce. What are the implications for practitioners? This study identifies the need to strengthen management understanding of lived experience to facilitate ongoing development of lived experience roles.

Objective The prevalence of life-limiting conditions in children in Australia is unknown; such data are needed to inform health service planning for paediatric palliative care. The aim of this study was to estimate the prevalence of life-limiting conditions for children and young people aged 0-21 years living in Queensland, Australia. Methods An observational study using linked administrative health data from the 2011 and 2016 calendar years was performed for all individuals with an International Statistical Classification of Diseases and Related Health Problems 10th Revision Australian Modification code relating to a life-limiting condition eligible for palliative care recorded against an admission to a public or private hospital and health service provider in Queensland or against a cause or underlying cause of death in the Queensland Registrar General Deaths. Results The overall prevalence of life-limiting conditions per 10000 population increased from 35.2 (95% confidence interval (CI) 34.2-36.2) in 2011 to 43.2 (95% CI 42.1-44.4) in 2016. This increase in prevalence was greatest for children <1 year of age and for those who identified as Aboriginal and Torres Strait Islander. Conclusion This study has estimated the prevalence of life-limiting conditions for children and young people aged 0-21 years living in Queensland. Estimation of the number of children and young people with life-limiting conditions can inform health service planning for paediatric palliative care in Queensland. Future research is needed to identify the number of children and young people with life-limiting conditions who do not have an admitted episode. What is known about the topic? Data from the UK indicate that the prevalence of life-limiting conditions among children and young people is increasing. However, such data are not available for the Australian population. Because prevalence data can be affected by population characteristics, it is important to establish country-specific epidemiological data rather than extrapolating data from other countries. Country-specific data can inform health planners and policy makers of the scale of the problem within a geographical and demographic context. This is essential for Australia given the diverse geographical and demographic characteristics and specific needs of Aboriginal and Torres Strait Islander peoples. What does this paper add? This study is the first to provide an estimate of the prevalence of life-limiting conditions in children and young people aged 0-21 years in Queensland. Estimates include the prevalence of life-limiting conditions in children and young people who identify as being of Aboriginal and/or Torres Strait Islander descent. What are the implications for practitioners? The prevalence of life-limiting conditions in Queensland is greater than previously thought. There is a need to grow both a generalist and specialist paediatric palliative care workforce in response to this increasing prevalence. The estimates of prevalence proportions from this study provide the foundation on which future health service activities can be built because they provide country-specific clinical and demographic characteristics.

Objective The aim of this study was to develop an effective digital survey instrument incorporating images to investigate Aboriginal and Torres Strait Islander preferences for health clinics and hospitals, design of healthcare settings and the differences between inner regional and remote locations. Methods Design-related constructs developed from qualitative interviews informed the construction of healthcare setting images. These images were embedded in an online survey instrument to elicit data on design preferences and an area-based recruitment strategy ensured participation by Indigenous Australians from three Queensland locations. Logistic regression analyses were used to estimate the odds of preference for a healthcare setting design by location. Results Statistical analysis of data from 602 participants showed a preference for health care at an Aboriginal and Torres Strait Islander clinic. The odds of preference for an in-patient room with a two- versus single-bed design was greater for participants with less education, and lower for participants with a long-term health problem. Conclusions The multidisciplinary approach to developing an online survey instrument with images and the willingness of Indigenous people of all ages to engage with the images demonstrated the effectiveness of this method in providing robust evidence for the design of culturally appropriate healthcare spaces for Indigenous users. What is known about the topic? Evidence-based research influences the design of healthcare buildings, yet the field currently provides negligible evidence on cross-cultural perceptions or experiences of conventional modern hospitals and clinics. Although recent healthcare buildings show signs of acknowledging Indigenous users, general principles in the Australian Health Facility Guidelines give limited specific information about how cultural requirements may translate into architectural design. What does this paper add? The multidisciplinary approach to research design has enabled the development of healthcare design-related constructs from consultation with Indigenous people, the presentation of these constructs as images and the inclusion of these images for comparison and selection in a digital survey instrument. Combined with a culturally appropriate recruitment strategy, this survey provides evidence from a large sample of the Indigenous population. Selected results from analyses of survey responses show the capacity of the methodological approach to address broader questions about Indigenous preferences for healthcare settings by location, age and sex. What are the implications for practitioners? A focus on individual preferences related to healthcare clinics and the combined significance of design and setting can give practitioners a better understanding of Aboriginal and Torres Strait Islander people's preferences and suggest ways to reduce the incidence of poor engagement with healthcare services.