Clarabelle Pham

A Systematic Review of Strategies to Improve Prophylaxis for Venous Thromboembolism in Hospitals

Objective:To assess the effectiveness of different strategies for increasing the uptake of prophylaxis for venous thromboembolism (VTE) in hospitalized patients through a systematic review of the literature. Methods:Literature databases and the Internet were searched from 1996 to May 2003. Studies of strategies to improve VTE prophylaxis practice were included. Studies where no policy or guideline was implemented or where the focus of the study was not VTE prevention were excluded. Results:Thirty studies were included. The quality of the available evidence was average with the majority of studies being uncontrolled before and after design and thus limited by the historical nature of much of the available data. Adherence to guidelines and the provision of adequate prophylaxis were poor in studies which relied on passive dissemination of guidelines. In general, the use of multiple strategies was more effective than a single strategy used in isolation. The most effective strategies incorporated a system for reminding clinicians to assess patients for VTE risk, either electronic decision-support systems or paper-based reminders, and used audit and feedback to facilitate the iterative refinement of the intervention. There were no studies adequately powered to demonstrate a reduction in rates of VTE. Insufficient evidence was available to make useful comparisons of strategies in terms of costs and resource utilization. Conclusions:Passive dissemination of guidelines is unlikely to improve VTE prophylaxis practice. A number of active strategies used together, which incorporate some method for reminding clinicians to assess patients for DVT risk and assisting the selection of appropriate prophylaxis, are likely to result in the achievement of optimal outcomes.

Birth outcomes: utility values that postnatal women, midwives and medical staff express

Objective To determine if and to what extent postnatal womens preferences for birth outcomes differ from those of midwives and medical staff, and whether any variations in utility scores are associated with demographic variables.

APPLYING RISK ADJUSTED COST-EFFECTIVENESS (RAC-E) ANALYSIS TO HOSPITALS: ESTIMATING THE COSTS AND CONSEQUENCES OF VARIATION IN CLINICAL PRACTICE

Cost-effectiveness analysis is well established for pharmaceuticals and medical technologies but not for evaluating variations in clinical practice. This paper describes a novel methodology--risk adjusted cost-effectiveness (RAC-E)--that facilitates the comparative evaluation of applied clinical practice processes. In this application, risk adjustment is undertaken with a multivariate matching algorithm that balances the baseline characteristics of patients attending different settings (e.g., hospitals). Linked, routinely collected data are used to analyse patient-level costs and outcomes over a 2-year period, as well as to extrapolate costs and survival over patient lifetimes. The study reports the relative cost-effectiveness of alternative forms of clinical practice, including a full representation of the statistical uncertainty around the mean estimates. The methodology is illustrated by a case study that evaluates the relative cost-effectiveness of services for patients presenting with acute chest pain across the four main public hospitals in South Australia. The evaluation finds that services provided at two hospitals were dominated, and of the remaining services, the more effective hospital gained life years at a low mean additional cost and had an 80% probability of being the most cost-effective hospital at realistic cost-effectiveness thresholds. Potential determinants of the estimated variation in costs and effects were identified, although more detailed analyses to identify specific areas of variation in clinical practice are required to inform improvements at the less cost-effective institutions.

Evaluating the effects of variation in clinical practice: a risk adjusted cost-effectiveness (RAC-E) analysis of acute stroke services

BackgroundMethods for the cost-effectiveness analysis of health technologies are now well established, but such methods may also have a useful role in the context of evaluating the effects of variation in applied clinical practice. This study illustrates a general methodology for the comparative analysis of applied clinical practice at alternative institutions – risk adjusted cost-effectiveness (RAC-E) analysis – with an application that compares acute hospital services for stroke patients admitted to the main public hospitals in South Australia.MethodsUsing linked, routinely collected data on all South Australian hospital separations from July 2001 to June 2008, an analysis of the RAC-E of services provided at four metropolitan hospitals was undertaken using a decision analytic framework. Observed (plus extrapolated) and expected lifetime costs and survival were compared across patient populations, from which the relative cost-effectiveness of services provided at the different hospitals was estimated.ResultsUnadjusted results showed that at one hospital patients incurred fewer costs and gained more life years than at the other hospitals (i.e. it was the dominant hospital). After risk adjustment, the cost minimizing hospital incurred the lowest costs, but with fewer life-years gained than one other hospital. The mean incremental cost per life-year gained of services provided at the most effective hospital was under

Profiling bone and joint problems and health service use in an Australian regional population: The Port Lincoln Health Study

20,000, with an associated 65% probability of being cost-effective at a

Managing high‐risk surgical patients: modifiable co‐morbidities matter

50,000 per life year monetary threshold.ConclusionsRAC-E analyses can be used to identify important variation in the costs and outcomes associated with clinical practice at alternative institutions. Such data provides an impetus for further investigation to identify specific areas of variation, which may then inform the dissemination of best practice service delivery and organisation.

A population analysis of self-management and health-related quality of life for chronic musculoskeletal conditions.

OBJECTIVES To describe the burden of bone and joint problems (BJP) in a defined regional population, and to identify characteristics and service-usage patterns. METHODS In 2010, a health census of adults aged ≥15 years was conducted in Port Lincoln, South Australia. A follow-up computer-assisted telephone interview provided more specific information about those with BJP. RESULTS Overall, 3350 people (42%) reported current BJP. General practitioners (GP) were the most commonly used provider (85%). People with BJP were also 85% more likely to visit chiropractors, twice as likely to visit physiotherapists and 34% more likely to visit Accident and Emergency or GP out of hours (compared with the rest of the population). Among the phenotypes, those with BJP with co-morbidities were more likely to visit GP, had a significantly higher mean pain score and higher levels of depression or anxiety compared with those with BJP only. Those with BJP only were more likely to visit physiotherapists. CONCLUSIONS GP were significant providers for those with co-morbidities, the group who also reported higher levels of pain and mental distress. GP have a central role in effectively managing this phenotype within the BJP population including linking allied health professionals with general practice to manage BJP more efficiently.

A comparison of propensity score‐based approaches to health service evaluation: a case study of a preoperative physician‐led clinic for high‐risk surgical patients

There are a subset of potentially modifiable co‐morbidities that may be targeted in the preoperative phase with a view to optimizing control and improving post‐operative outcomes. This study aims to estimate the effect of potentially modifiable co‐morbidities on post‐operative outcomes and to identify potential targets for preoperative management.

A cost-effectiveness analysis of freeze-only or fresh embryo transfer in IVF of non-PCOS women

Background There is growing policy emphasis on self-management as an essential component of musculoskeletal chronic care models. Underpinning this drive is the assumption that with correct ‘informational’ framing people will better manage their conditions progression and thereby maintain quality of life. Objective To assess associations between self-management behaviours and health-related quality of life for people with chronic musculoskeletal conditions. Design Using survey data from health census and follow-up structured telephone interviews, linear regression (cumulatively adjusted for potential confounders) and logistic regression examined associations between use of specific self-management behaviours and quality of life. Setting and participants A total of 885 respondents (2012) who indicated still having a musculoskeletal condition reported in a 2010 health census (Port Lincoln, South Australia). Variables Specific self-management activities, age, sex, education, marital status, smoking, comorbidities and pain. Outcome measure EQ-5D-5L. Results Exercise (63%) and diet (19%) were the most commonly reported self-management activities used to manage musculoskeletal conditions. About 24% reported not using any specific self-management activities. Involvement in self-management showed no association with quality of life, with and without adjustment for confounders. Diet had a negative association with quality of life as did use of formal support (self-management course or community group support). Discussion Taking a real-world perspective, these findings raise important questions about how people currently engage with self-management activities and the kinds of outcomes that can be expected from undertaking these activities. The timing of peoples uptake of self-management within the musculoskeletal disease continuum is an issue requiring further attention in both research and practice.Background There is growing policy emphasis on self-management as an essential component of musculoskeletal chronic care models. Underpinning this drive is the assumption that with correct ‘informational’ framing people will better manage their conditions progression and thereby maintain quality of life. Objective To assess associations between self-management behaviours and health-related quality of life for people with chronic musculoskeletal conditions. Design Using survey data from health census and follow-up structured telephone interviews, linear regression (cumulatively adjusted for potential confounders) and logistic regression examined associations between use of specific self-management behaviours and quality of life. Setting and participants A total of 885 respondents (2012) who indicated still having a musculoskeletal condition reported in a 2010 health census (Port Lincoln, South Australia). Variables Specific self-management activities, age, sex, education, marital status, smoking, comorbidities and pain. Outcome measure EQ-5D-5L. Results Exercise (63%) and diet (19%) were the most commonly reported self-management activities used to manage musculoskeletal conditions. About 24% reported not using any specific self-management activities. Involvement in self-management showed no association with quality of life, with and without adjustment for confounders. Diet had a negative association with quality of life as did use of formal support (self-management course or community group support). Discussion Taking a real-world perspective, these findings raise important questions about how people currently engage with self-management activities and the kinds of outcomes that can be expected from undertaking these activities. The timing of peoples uptake of self-management within the musculoskeletal disease continuum is an issue requiring further attention in both research and practice.There is growing policy emphasis on self‐management as an essential component of musculoskeletal chronic care models. Underpinning this drive is the assumption that with correct ‘informational’ framing people will better manage their conditions progression and thereby maintain quality of life.

Timing of elective pre-labour caesarean section: A decision analysis

RATIONALE, AIMS AND OBJECTIVES A physician-led clinic for the preoperative optimization and management of high-risk surgical patients was implemented in a South Australian public hospital in 2008. This study aimed to estimate the costs and effects of the clinic using a mixed retrospective and prospective observational study design. METHOD Alternative propensity score estimation methods were applied to retrospective routinely collected administrative and clinical data, using weighted and matched cohorts. Supplementary survey-based prospective data were collected to inform the analysis of the retrospective data and reduce potential unmeasured confounding. RESULTS Using weighted cohorts, clinic patients had a significantly longer mean length of stay and higher mean cost. With the matched cohorts, reducing the calliper width resulted in a shorter mean length of stay in the clinic group, but the costs remained significantly higher. The prospective data indicated potential unmeasured confounding in all analyses other than in the most tightly matched cohorts. CONCLUSIONS The application of alternative propensity-based approaches to a large sample of retrospective data, supplemented with a smaller sample of prospective data, informed a pragmatic approach to reducing potential observed and unmeasured confounding in an evaluation of a physician-led preoperative clinic. The need to generate tightly matched cohorts to reduce the potential for unmeasured confounding indicates that significant uncertainty remains around the effects of the clinic. This study illustrates the value of mixed retrospective and prospective observational study designs but also underlines the need to prospectively plan for the evaluation of costs and effects alongside the implementation of significant service innovations.