Health services administration

Suicide prevention initiatives should focus on workplace factors and differential risks for men and women employed as health professionals

Allison J Milner · Humaira Maheen · Marie M Bismark · Matthew J Spittal

Closing the Indigenous gap could have far-reaching benefits for the economic future of the Territory

Yuejen Zhao · Siva R Vemuri · Dinesh Arya

Recent Cochrane reviews

Steve McDonald · Tari Turner

The current ethics review process is inappropriate for clinical quality registries

Wendy A Brown · Brittany R Smith · Melissa Boglis · Dianne L Brown · Margaret Anderson · Paul E O'Brien · John J McNeil · Ian D Caterson

Inspection of the jugular veins provides a simple means of determining whether pressures in the right side of the heart are normal or elevated

Andrew Elder · Balakrishnan (Kichu) R Nair

Chronically ill patients without concession cards may save money through non-PBS bulk prescriptions

Susanne P O'Malley

The concept is attractive — but capacity may limit its practicality

Andrew H Singer

WBA is a reliable method if multiple tools and assessors are used over a period of time

Balakrishnan (Kichu) R Nair · Joyce MW Moonen-van Loon · Mulavana S Parvathy · Cees PM van der Vleuten

There are strong associations between rural GP vocational training location and subsequent rural practice location

Matthew R McGrail · Deborah J Russell · David G Campbell

The lower rate of coronary angiography is the key disparity in the care of Aboriginal patients with acute coronary syndromes

Rosanna Tavella · Katharine McBride · Wendy Keech · Janet Kelly · Amanda Rischbieth · Christopher Zeitz · John F Beltrame · Philip A Tideman · Alex Brown

Diabetes rapid access clinics (DRACs) have been identified by the New South Wales Agency for Clinical Innovation as a key component of an integrated diabetes model of care.1 This cost-effective model provides fast and comprehensive outpatient review and has been shown to circumvent hospital admission, decrease hospital length of stay and improve patient outcomes.2-5 Based on this approach, a nurse practitioner-led DRAC was established in February 2015 at Royal North Shore Hospital (RNSH) in Sydney as a pilot program to assess the suitability of the DRAC for scalability across the Northern Sydney Local Health District (NSLHD). The DRAC is an outpatient clinic, operating on weekdays, which adopts the principle that high-risk patients who present to the emergency department (ED) could be diverted from hospitalisation if they were well enough for outpatient management of their condition (Appendix). Patients are referred from general practice, the ED or the endocrinologist on call and require rapid review (within 72 hours) of complex diabetes problems, such as an episode (or episodes) of severe hypoglycaemia, recurring mild hypoglycaemia or hyperglycaemia not needing hospitalisation. We prospectively collected data during the first year since inception of the DRAC, with a particular focus on reasons for referral and cost evaluation. The study was approved by the NSLHD Human Research Ethics Committee (RESP/16/62). Within the first year of the DRAC pilot program at RNSH, 61 patients attended the clinic. About a quarter of these patients (n = 15) would have been hospitalised had they not been reviewed at the DRAC and they were successfully managed as outpatients. Although these patients met the criteria for admission, they were deemed appropriate for the DRAC by the endocrinologist on call. In addition, 26% of the patients were referred back to general practice, while the remainder required ongoing endocrinologist review. Most patients presented with hyperglycaemia-related problems (n = 40; 66%; Box), including 15 patients with newly diagnosed diabetes. A further 11 patients presented with severe hypoglycaemia. Within 30 days of review at the DRAC, one patient presented to the ED and required hospitalisation. Using a conservative costing approach, whereby patients were assumed to be uncomplicated with an average length of stay of 2.5 days (based on data from the NSLHD Performance Unit), the cost analysis demonstrated that for 15 patients for whom hospitalisation was avoided, about $46 700 would have been incurred in their inpatient stay. The DRAC was established through a restructure of existing services; however, if nursing costs associated with running the DRAC were included (about $23 400), the analysis showed that the cost of management in the clinic was half the cost of an inpatient stay (Box). A nurse practitioner-led DRAC was successfully established at a tertiary referral hospital in NSW. Our preliminary evaluation has demonstrated improved patient outcomes and assistance for general practice in managing ongoing outpatient diabetes-related problems. In addition, for a quarter of patients presenting to the DRAC, hospitalisation was prevented. Future directions include the expansion of the DRAC across the local health district and the incorporation of a “hotline” to assist general practitioners with urgent and complex diabetes management. Box – Royal North Shore Hospital Diabetes Rapid Access Clinic (DRAC) evaluation: overview of patient demographics and cost analysis data Patient demographic No. of patients* Patients seen (February – December 2015) 61 Male 42 Mean age, years (SD) 56 ± 16 Mean glycated haemoglobin value (SD) 9.7% ± 2.5% Mean duration of diabetes, years (SD) 13 ± 13 Type 1 diabetes 14 (23%) Type 2 diabetes 47 (77%) Reason for referral to DRAC Newly diagnosed type 1 diabetes 2 Newly diagnosed type 2 diabetes 13 Hyperglycaemia 25 Hypoglycaemia (severe) 11 Other 10 Cost analysis No. of hospitalisations prevented† 15 (25%) Hospitalisation cost per day $1245 Average length of stay, days 2.5 Total hospitalisation cost that would have been incurred $46 687.50 Cost of nursing at DRAC $23 339.52 Cost management difference $23 347.98 * Data are number of patients unless otherwise indicated. † One patient sent to the emergency department via DRAC — not diabetes related.

Neroli Newlyn · Rachel T McGrath · Gregory R Fulcher

An absolute cardiovascular risk approach will better target patients who need pharmacotherapy

Mark R Nelson

An integrated approach incorporating both physical and mental health is critical to “congenital heart health”

Nadine A Kasparian · David S Winlaw · Gary F Sholler

We need to ensure that those who need care most receive it

Ian A Scott

A focus on clinical care standards and better health service distribution is needed to reduce variation in angiography rates

Derek P Chew · Andrew I MacIsaac · Jeffrey Lefkovits · Richard W Harper · Luke Slawomirski · David Braddock · Matthew J Horsfall · Heather A Buchan · Chris John Ellis · David B Brieger · Tom G Briffa

The use of coronary pressure wires (or fractional flow reserve [FFR]) has been shown to reduce the frequency of major adverse cardiac events and of unnecessary stent procedures, and to lower treatment costs in both the public and private sectors in Australia.1-3 FFR is a tool for assessing physiological ischaemia in coronary artery stenosis, measuring pre- and post-stenosis pressures during adenosine-induced hyperaemia. Because it is evidence-based and quantifiable, it may be discussed during the upcoming Medicare reform. Data on its uptake across Australia, however, have not been published. We examined trends in FFR use after its addition to the Medicare Benefits Schedule 10 years ago. We analysed Australian Government Department of Human Services data on Medicare items for coronary flow reserve, coronary angiography and percutaneous coronary angiography. A total of 14 160 FFR services were processed by Medicare during the past 10 years. FFR use grew during this period, with a mean annual increase of 55%, from 131 services in 2007 to 3869 in 2015 (non-parametric analysis, P = 0.004). Time series analysis identified a Gompertz non-linear trend of FFR against time, indicating that national FFR use is continuing to increase, although growth began to slow in 2014. Further, FFR use increased on a population basis by an average of 45% each year, from 1 per 100 000 in 2007 to 16 per 100 000 in 2015, when these figures were highest in New South Wales (23 per 100 000) and Queensland (19 per 100 000) (Box). The national rate of FFR per coronary angiogram increased from 0.02% in 2006 to 4.8% in 2015 (P = 0.004), when the highest rate was in NSW (5.8%). The rate of FFR per percutaneous coronary intervention (PCI) increased from 0.1% in 2006 to 19.2% in 2015 (P = 0.004), when the highest rate was in Queensland (26.6%). In 2015, there were 5.2 PCIs per FFR used; the rate was not related to the population size of the state or territory (Spearman non-parametric correlation, ρS = 0.07; P = 0.87) or to total PCI use (ρS = 0.12, P = 0.78). There was marked variation between states and territories (Box), highlighting heterogeneity across Australia in the use of FFR. The data summarised in the Box allow operators and hospitals to compare their use of FFR with state and national averages, and they facilitate more standardised care across Australia. Barriers to the uptake of FFR include operator and centre experience, availability and cost. It has been suggested that FFR is discouraged by the lower remuneration received if stenting is not performed.4 From a national perspective, however, there is a mean saving of $1200 per patient in the public sector and $5000 per patient in the private sector when FFR makes stenting unnecessary,2 representing a total annual saving of $4 million.4 The use of FFR across Australia is heterogeneous, but it has grown over the past decade, both in absolute numbers and as proportions of coronary angiograms and PCI. Box – Summary of Medicare items for use of a coronary pressure wire (fractional flow reserve [FFR]) processed during 2015 Australia NSW Vic Qld SA WA Tas ACT NT Total FFR services 3869 1764 688 944 146 225 77 11 14 FFR per 100 000 population 16 23 11 19 8 9 15 3 6 FFR per angiogram 1/21 (4.8%) 1/17 (5.8%) 1/28 (3.6%) 1/17 (5.7%) 1/30 (3.4%) 1/29 (3.5%) 1/21 (4.8%) 1/83 (1.2%) 1/38 (2.7%) FFR per percutaneous coronary intervention 1/5.2 (19.2%) 1/4.6 (21.6%) 1/7.0 (14.3%) 1/3.8 (26.6%) 1/6.8 (14.7%) 1/7.7 (13.0%) 1/6.2 (16.2%) 1/34.1 (2.9%) 1/4.3 (23.3%) Source: Australian Government Department of Human Services. Medicare Australia Statistics, medical item reports (http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp) for coronary flow reserve (item number, 38241), coronary angiogram (38215, 38218, 38220, 38222, 38225, 38228, 38231, 38234, 38237, 38240, 38246) and percutaneous coronary angiogram (38243, 38246).

Austin N May · Anthony Kull · Brendan Gunalingam · J Lynn Francis · George T Lau

An updated guideline providing a synthesis of current evidence-based guidance for health professionals caring for patients with ACS

Derek P Chew · Ian A Scott · Louise Cullen · John K French · Tom G Briffa · Philip A Tideman · Stephen Woodruffe · Alistair Kerr · Maree Branagan · Philip EG Aylward

A focus on helmet legislation detracts from concerns about cycling infrastructure and safety

Jake Olivier · Soufiane Boufous · Raphael H Grzebieta

Cuts to federal funding put us in grave danger of wasting the investment made to achieve current gains in research capacity

Tania M Winzenberg · Gerard F Gill

Intensive acute hospital physiotherapy is safe and reduces the length of hospital stay

Lara A Kimmel · Susan M Liew · James M Sayer · Anne E Holland