While health services and their clinicians might seek to be innovative, finite budgets, increased demands on health services, and ineffective implementation strategies create challenges to sustaining innovation. These challenges can be addressed by building staff capacity to design cost-effective, evidence-based innovations, and selecting appropriate implementation strategies. A bespoke university award qualification and associated program of activities was developed to build the capacity of staff at Australia's largest health service to implement and evaluate evidence-based practice (EBP): a Graduate Certificate in Health Science majoring in Health Services Innovation. The aim of this study was to establish the health service's pre-program capacity to implement EBP and to identify preliminary changes in capacity that have occurred as a result of the Health Services Innovation program.A mixed methods design underpinned by the Consolidated Framework for Implementation Research informed the research design, data collection, and analysis. Data about EBP implementation capacity aligned to the framework constructs were sought through qualitative interviews of university and health service executives, focus groups with students, and a quantitative survey of managers and students. The outcomes measured were knowledge of, attitudes towards, and use of EBP within the health service, as well as changes to practice which students identified had resulted from their participation in the program.The Health Services Innovation program has contributed to short-term changes in health service capacity to implement EBP. Participating students have not only increased their individual skills and knowledge, but also changed their EPB culture and practice which has ignited and sustained health service innovations and improvements in the first 18 months of the program. Capacity changes observed across wider sections of the organization include an increase in connections and networks, use of a shared language, and use of robust implementation science methods such as stakeholder analyses.This is a unique study that assessed data from all stakeholders: university and health service executives, students, and their managers. By assembling multiple perspectives, we identified that developing the social capital of the organization through delivering a full suite of capacity-building initiatives was critical to the preliminary success of the program.
Musculoskeletal conditions of the foot and ankle are common, yet the cost-effectiveness of the variety of treatments available is not well defined. The aim of this systematic review was therefore to identify, appraise, and synthesize the literature pertaining to the cost-effectiveness of interventions for musculoskeletal foot and ankle conditions.Electronic databases were searched for studies presenting economic evaluations of nonsurgical and surgical treatments for acute or chronic musculoskeletal conditions of the foot and ankle. Data on cost, incremental cost-effectiveness, and quality-adjusted life years for each intervention and comparison were extracted. Risk of bias was assessed using the Drummond checklist for economic studies (range 0-35).Thirty-six studies were identified reporting nonsurgical interventions (n = 10), nonsurgical versus surgical interventions (n = 14), and surgical interventions (n = 12). The most common conditions were osteoarthritis, ankle fracture, and Achilles tendon rupture. The strongest economic evaluations were for interventions managing end-stage ankle osteoarthritis, ankle sprain, ankle fracture, calcaneal fracture, and Achilles tendon rupture. Total ankle replacement and ankle arthrodesis for end-stage ankle osteoarthritis, in particular, have been demonstrated through high-quality studies to be cost-effective compared to the nonsurgical alternative.Selected interventions for musculoskeletal foot and ankle conditions dominate comparators, whereas others require thoughtful consideration as they provide better clinical improvements, but at an increased cost. Researchers should consider measuring and reporting costs alongside clinical outcome to provide context when determining the appropriateness of interventions for other foot and ankle symptoms to best inform future clinical practice guidelines.
Antimicrobial resistance is a growing worldwide problem and is considered to be one of the biggest threats to global health by the World Health Organization. Insights into the determinants of antibiotic prescribing may be gained by comparing the antibiotic usage patterns of Australia and Sweden.Publicly available data on dispensed use of antibiotics in Australia and Sweden between 2006 and 2018. Medicine use was measured using defined daily dose per 1,000 inhabitants per day (DDD/1000/day) and the number of dispensed prescriptions per 1000 inhabitants (prescriptions/1000).The use of antibiotics increased over the study period in Australia by 1.8% and decreased in Sweden by 26.3%. Use was consistently higher in Australia, double that of Sweden in 2018. Penicillin with extended spectrum was the most used class of antibiotics in Australia followed by penicillin with beta lactamase inhibitors. In Sweden, the most used class was beta lactamase-sensitive penicillin and the least used class was penicillin with beta lactamase inhibitors.Antibiotic use in Australia is higher than in Sweden, with a higher proportion of broad-spectrum penicillin, including combinations with beta lactamase inhibitors, and cephalosporins. Factors that may contribute to these differences in antibiotic use include differences in guidelines, the duration of national antimicrobial stewardship programs, and differences in funding mechanisms.Key pointsAustralia has had a consistently higher dispensed use of antibiotics compared to Sweden from 2006 to 2018; and up to twice the use in 2018•A higher proportion of dispensed antibiotics in Australia were broad-spectrum penicillin, including combinations with beta lactamase inhibitors, and cefalosporins.•The most commonly used class of antibiotics in Australia is penicillin with extended spectrum, compared to beta lactamase sensitive penicillin in Sweden.•Use of macrolides, sulphonamides and trimethoprim, cephalosporins, penicillin with beta lactamase inhibitors and penicillin with extended spectrum was consistently higher in Australia, whereas in Sweden use of fluoroquinolones, lincosamides, beta lactamase-resistant penicillin and beta lactamase sensitive penicillin was higher.•The observed differences could be explained by antibiotic choice recommended in guidelines, prevalence of point-of-care testing, models of primary care funding, the presence and duration of national antimicrobial stewardship programmes, and cultural differences.
To determine the incidence, outcomes, and evaluate diagnostic modalities for postoperative vocal cord dysfunction (VCD) following cardiothoracic surgery in children.A prospective mixed-methods study using principles of implementation science was completed. All patients undergoing surgery involving the aortic arch, ductus, or ligamentum arteriosum and vascular rings from September 2019 to December 2020 were enrolled. Patients underwent speech pathology assessment, laryngeal ultrasound, and flexible direct laryngoscopy.Ninety-five patients were eligible for inclusion. The incidence of VCD ranged from 18% to 56% and varied according to procedure group. VCD occurred in 42% of neonates. Repair of hypoplastic aortic arch was associated with increased risk of VCD (57%; P = .002). There was no significant difference in duration of intubation, pediatric intensive care unit stay, or hospital stay. Forty percent children were able to achieve full oral feeding. Children with VCD were more likely to require nasogastric supplementary feeding at discharge (60% vs 36%; P = .044). Sixty-eight percent of patients demonstrated complete resolution of VCD at a median of 97 days postoperatively. Laryngeal ultrasound and speech pathology assessment combined had a sensitivity of 91% in comparison to flexible direct laryngoscopy.VCD occurred in one-third and resolved in two-thirds of patients at a median of 3 months following cardiac surgery. Aortic arch repair carried the highest risk of VCD. VCD adversely influenced feeding. Forty percent of patients achieved full oral feeding before discharge. VCD did not delay intensive care unit or hospital discharge. Speech pathology assessment and laryngeal ultrasound combined was reliable for diagnosis in most patients and was more patient friendly than flexible direct laryngoscopy.
AusHSI regularly delivers short courses on cost-effectiveness analysis. Recently they had a special group of customers: health librarians from across Australia.
Background: The Australian Government released a national strategy for antimicrobial resistance in 2015 that calls for a collaborative effort to change practices that have contributed to the development of drug-resistant infection and for the implementation of new initiatives to reduce antibiotic use. Although many achievements have been made in antimicrobial stewardship (AMS), particularly in the acute-care hospital setting, progress more broadly has been slow, and novel solutions are now required to improve clinical practice and community awareness. A facilitated workshop was undertaken at the 2019 National Australian Antimicrobial Resistance Forum to explore the complexity of AMS implementation in Australia and to prioritize future action. Methods: Participants engaged in rotating rounds of discussion using a world café format. The participants sat face-to-face at tables of 7 or fewer. At each table were 2 facilitators: one was a note taker and the other was the discussion leader. Each of the 6 facilitator pairs had a topic for discussion related to implementing antimicrobial stewardship in different contexts, with a focus on experience with strategies that have worked, major implementation barriers, and prioritizing the next steps. The topics for discussion included (1) engaging with hospital staff; (2) implementation in resource-poor settings; (3) implementation in primary care and aged care; (4) engaging and empowering the public; (5) linking data with implementation strategies; and (6) leadership. The facilitators moved between tables at 15-minute intervals to encourage evolving rounds of conversation. Once all tables had discussed all of the themes, the discussion concluded and notes were summarized. A qualitative analysis using an interpretive description approach was conducted using the discussion summaries. The documents were independently openly coded by 2 researchers to identify elements relating to the implementation of antimicrobial stewardship. An iterative approach was used to identify themes and reach a consensus on overarching emergent themes from the workshop. Results: In total, 39 experts (ie, pharmacists, infectious disease physicians, infection prevention nurses, researchers, journalists and consumers) participated in the facilitated discussions. Strategies were discussed relating to engaging with clinicians, consumers, and politicians; adapting to funding, governance, and accreditation limitations; and models for outreach of antimicrobial services. Other themes included the role of clinical champions and mentors as leaders and improving use of audit and feedback through focusing on monitoring appropriateness rather than usage. Conclusions: Recommendations from the workshop will be used to prioritize novel ideas to improve the implementation of AMS initiatives across Australia. Funding: None Disclosures: None
Abstract Background and Aim Clostridium difficile is the most common cause of hospital‐acquired diarrhea in Australia. In 2013, a randomized controlled trial demonstrated the effectiveness of fecal microbiota transplantation (FMT) for the treatment of recurrent Clostridium difficile infection (CDI). The aim of this study is to evaluate the cost‐effectiveness of fecal microbiota transplantation—via either nasoduodenal or colorectal delivery—compared with vancomycin for the treatment of recurrent CDI in Australia. Methods A Markov model was developed to compare the cost‐effectiveness of fecal microbiota transplantation compared with standard antibiotic therapy. A literature review of clinical evidence informed the structure of the model and the choice of parameter values. Clinical effectiveness was measured in terms of quality‐adjusted life years. Uncertainty in the model was explored using probabilistic sensitivity analysis. Results Both nasoduodenal and colorectal FMT resulted in improved quality of life and reduced cost compared with vancomycin. The incremental effectiveness of either FMT delivery compared with vancomycin was 1.2 (95% CI: 0.1, 2.3) quality‐adjusted life years, or 1.4 (95% CI: 0.4, 2.4) life years saved. Treatment with vancomycin resulted in an increased cost of AU$4094 (95% CI: AU$26, AU$8161) compared with nasoduodenal delivery of FMT and AU$4045 (95% CI: −AU$33, AU$8124) compared with colorectal delivery. The mean difference in cost between colorectal and nasoduodenal FMT was not significant. Conclusions If FMT, rather than vancomycin, became standard care for recurrent CDI in Australia, the estimated national healthcare savings would be over AU$4000 per treated person, with a substantial increase in quality of life.
Abstract Aim To determine the effectiveness of therapeutic activity kits on health service use and treatment delivered in the emergency department (ED) in patients with pre‐morbid dementia. Design Pragmatic randomized control trial with equal parallel groups. Methods Participants with dementia will be randomly assigned to the control group ( N = 56) or the intervention group ( N = 56). The intervention group will be given access to a therapeutic activity kit containing several different activities and sensory stimuli to engage the person with dementia during their ED stay in addition to usual care, and the control group will be given usual care only. A research nurse will observe participants at 30–60‐min intervals throughout their ED stay for responsive behaviours, one‐on‐one nursing, and the use of chemical and physical restraint. This study has received Research Ethics Committee approval from the institutional review board and funding from the Rosemary Bryant Foundation (May 2019). Discussion Emergency departments are busy and noisy environments and can be intimidating and disorientating for patients with dementia, which can result in responsive behaviours. Responsive behaviours are often managed with restrictive interventions, such as chemical or physical restraint, or with constant bedside nursing (one‐on‐one nursing) to ensure patient safety. Alternatively, non‐restrictive and non‐pharmacological interventions that divert or occupy the attention of patients such as those contained in the therapeutic activity kit can be considered as a more person‐centred strategy. Therapeutic activity kits have been reported as feasible for the use in ED; however, there is limited quality evidence at present to support the implementation of such interventions in the ED. Impact If this study is successful, it will demonstrate that a therapeutic activity kit containing activities (puzzles, colouring, music, and tactile activities) is inexpensive, easily implemented intervention that can prevent this patient group from demonstrating unsafe behaviours and requiring one‐on‐one nursing and restraints.
Abstract Background Analysis of multi‐institutional data and benchmarking is an accepted accreditation standard in cardiac surgery. Such a database does not exist for congenital cardiac surgery in Australia and New Zealand (ANZ). To fill this gap, the ANZ Congenital Outcomes Registry for Surgery (ANZCORS) was established in 2017. Methods Inclusion criteria included all cardiothoracic and extracorporeal membrane oxygenation (ECMO) procedures performed at five participating centres. Data was collected by data managers, validated by the surgical team, and securely transmitted to a central repository. Results Between 2015 and 2019, 9723 procedures were performed in 7003 patients. Cardiopulmonary bypass was utilized for 59% and 9% were ECMO procedures. Fifty‐seven percent ( n = 5531) of the procedures were performed in children younger than 1 year of age. Twenty‐four percent of procedures ( n = 2365) were performed in neonates (≤28 days) and 33% ( n = 3166) were performed in children aged 29 days to 1 year (infants). The 30‐day mortality for cardiac cases ( n = 6572) was 1.3% and there was no statistical difference between the participating centres ( P = 0.491). Sixty‐nine percent of cases had no major post‐operative complications (5121/7456). For cardiopulmonary bypass procedures ( n = 5774), median stay in intensive care and hospital was 2 days (IQR 1, 4) and 9 days (IQR 5, 18), respectively. Conclusion ANZCORS has facilitated pooled data analysis for paediatric cardiac surgery across ANZ for the first time. Overall mortality was low. Non‐risk‐adjusted 30‐day mortality for individual procedures was similar in all units. The continued evaluation of surgical outcomes through ANZCORS will drive quality assessment in paediatric cardiac surgery across ANZ.
Background Individuals with lower limb amputation fitted with conventional artificial limbs often experience continuous socket-related discomfort leading to a dramatic decrease in quality of life. Most of these functional issues can be overcome by replacing the socket with a surgically implanted bone-anchored prosthesis attached directly to the residual bone using an osseointegrated fixation.[1-31] Government organizations are facing challenges in adjusting procedures to accommodate the emergence of bone-anchored prostheses.[32-35] This study shares the knowledge gained by the Queensland Artificial Limb Service (QALS) an Australian State government organization, while implementing a procedure for fair and equitable provision of bone-anchored prostheses care. Aim The aim of this study was to share some insights drawn from QALS’ experience with strong emphasis on barriers and facilitators encountered when implementing procedure for provision of bone-anchored prostheses care in Queensland, Australia. Method Barriers and facilitators were identified over nearly 3 years following typical phases of action research led by QALS’ management team and researchers who consulted key stakeholders (e.g., 18 Queensland - based consumers, 3 prosthetists, 2 multidisciplinary clinical teams).
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