Shanthi Ramanathan

Assessing the appropriateness of prevention and management of venous thromboembolism in Australia: a cross-sectional study

Objectives The prevention and management of venous thromboembolism (VTE) is often at variance with guidelines. The CareTrack Australia (CTA) study reported that appropriate care (in line with evidence-based or consensus-based guidelines) is being provided for VTE at just over half of eligible encounters. The aim of this paper is to present and discuss the detailed CTA findings for VTE as a baseline for compliance with guidelines at a population level. Setting The setting was 27 hospitals in 2 states of Australia. Participants A sample of participants designed to be representative of the Australian population was recruited. Participants who had been admitted overnight during 2009 and/or 2010 were eligible. Of the 1154 CTA participants, 481(42%) were admitted overnight to hospital at least once, comprising 751 admissions. There were 279 females (58%), and the mean age was 64 years. Primary and secondary outcome measures The primary measure was compliance with indicators of appropriate care for VTE. The indicators were extracted from Australian VTE clinical practice guidelines and ratified by experts. Participants’ medical records from 2009 to 2010 were analysed for compliance with 38 VTE indicators. Results Of the 35 145 CTA encounters, 1078 (3%) were eligible for scoring against VTE indicators. There were 2–84 eligible encounters per indicator at 27 hospitals. Overall compliance with indicators for VTE was 51%, and ranged from 34% to 64% for aggregated sets of indicators. Conclusions The prevention and management of VTE was appropriate for only half of the at-risk patients in our sample; this provides a baseline for tracking progress nationally. There is a need for national and, ideally, international agreement on clinical standards, indicators and tools to guide, document and monitor care for VTE, and for measures to increase their uptake, particularly where deficiencies have been identified.

Quality of Health Care for Children in Australia, 2012-2013.

Importance The quality of routine care for children is rarely assessed, and then usually in single settings or for single clinical conditions. Objective To estimate the quality of health care for children in Australia in inpatient and ambulatory health care settings. Design, Setting, and Participants Multistage stratified sample with medical record review to assess adherence with quality indicators extracted from clinical practice guidelines for 17 common, high-burden clinical conditions (noncommunicable [n = 5], mental health [n = 4], acute infection [n = 7], and injury [n = 1]), such as asthma, attention-deficit/hyperactivity disorder, tonsillitis, and head injury. For these 17 conditions, 479 quality indicators were identified, with the number varying by condition, ranging from 9 for eczema to 54 for head injury. Four hundred medical records were targeted for sampling for each of 15 conditions while 267 records were targeted for anxiety and 133 for depression. Within each selected medical record, all visits for the 17 targeted conditions were identified, and separate quality assessments made for each. Care was evaluated for 6689 children 15 years of age and younger who had 15 240 visits to emergency departments, for inpatient admissions, or to pediatricians and general practitioners in selected urban and rural locations in 3 Australian states. These visits generated 160 202 quality indicator assessments. Exposures Quality indicators were identified through a systematic search of local and international guidelines. Individual indicators were extracted from guidelines and assessed using a 2-stage Delphi process. Main Outcomes and Measures Quality of care for each clinical condition and overall. Results Of 6689 children with surveyed medical records, 53.6% were aged 0 to 4 years and 55.5% were male. Adherence to quality of care indicators was estimated at 59.8% (95% CI, 57.5%-62.0%; n = 160 202) across the 17 conditions, ranging from a high of 88.8% (95% CI, 83.0%-93.1%; n = 2638) for autism to a low of 43.5% (95% CI, 36.8%-50.4%; n = 2354) for tonsillitis. The mean adherence by condition category was estimated as 60.5% (95% CI, 57.2%-63.8%; n = 41 265) for noncommunicable conditions (range, 52.8%-75.8%); 82.4% (95% CI, 79.0%-85.5%; n = 14 622) for mental health conditions (range, 71.5%-88.8%); 56.3% (95% CI, 53.2%-59.4%; n = 94 037) for acute infections (range, 43.5%-69.8%); and 78.3% (95% CI, 75.1%-81.2%; n = 10 278) for injury. Conclusions and Relevance Among a sample of children receiving care in Australia in 2012-2013, the overall prevalence of adherence to quality of care indicators for important conditions was not high. For many of these conditions, the quality of care may be inadequate.

General practitioner referral patterns for women with gynaecological symptoms: a randomised incomplete block study design

Objective: To describe why, when and to whom general practitioners refer women with symptoms possibly attributable to cervical, endometrial or ovarian cancers, and to identify patient and GP factors that predict referral to either a gynaecologist or a gynaecological oncologist.

Care Track: Towards Appropriate Care for Low Back Pain.

Study Design. Retrospective medical record review to assess compliance with low back pain (LBP) care indicators. Objective. To establish baseline estimates of the appropriateness of LBP care in the general Australian population provided by a range of healthcare providers in various real-world settings. Summary of Background Data. LBP is a costly condition and accounts for the greatest burden of disease worldwide, yet the care provided is often at variance with guidelines. No baseline estimates of performance are currently available in Australia across various aspects of LBP care, practitioners, and settings. Methods. A population-based sample of patients with 22 common conditions was recruited by telephone; consents were obtained to review their medical records against indicators (“CareTrack”). Care for LBP was reviewed against 10 indicators used in a previous study and ratified by experts as representing appropriate LBP care in Australia during 2009 and 2010. Results. Of the 22 CareTrack conditions, LBP had the highest number of eligible healthcare encounters (6588 of 35,573, 19%), 125 to 884 per indicator among 164 LBP patients. Overall compliance with LBP indicators was 72% (range 42%–98%). Allied health practitioners and hospitals were the most compliant (82%–83% respectively), followed by general practitioners (54%). Some aspects of care were poor, such as documenting a thorough neurological examination, screening for serious diseases such as infection and inappropriate use of drugs such as steroids and treatments such as traction. Conclusion. Over a quarter of LBP care was not appropriate despite the availability of guidelines. There is a need for national and, potentially, international agreement on clinical standards, indicators and tools to guide, document and monitor the appropriateness of care for LBP, and for measures to increase their uptake, particularly where deficiencies have been identified. Level of Evidence: N /A

Encouraging translation and assessing impact of the Centre for Research Excellence in Integrated Quality Improvement: rationale and protocol for a research impact assessment

Introduction There is growing recognition among health researchers and funders that the wider benefits of research such as economic, social and health impacts ought to be assessed and valued alongside academic outputs such as peer-reviewed papers. Research translation needs to increase and the pathways to impact ought to be more transparent. These processes are particularly pertinent to the Indigenous health sector given continued concerns that Indigenous communities are over-researched with little corresponding improvement in health outcomes. This paper describes the research protocol of a mixed methods study to apply FAIT (Framework to Assess the Impact from Translational health research) to the Centre for Research Excellence in Integrated Quality Improvement (CRE-IQI). FAIT will be applied to five selected CRE-IQI Flagship projects to encourage research translation and assess the wider impact of that research. Methods and analysis Phase I will develop a modified programme logic model for each Flagship project including identifying process, output and impact metrics so progress can be monitored. A scoping review will inform potential benefits. In phase II, programme logic models will be updated to account for changes in the research pathways over time. Audit and feedback will be used to encourage research translation and collect evidence of achievement of any process, output and interim impacts. In phase III, three proven methodologies for measuring research impact—Payback, economic assessment and narratives—will be applied. Data on the application of FAIT will be collected and analysed to inform and improve FAIT’s performance. Ethics and dissemination This study is funded by a nationally competitive grant (ID 1078927) from the Australian National Health and Medical Research Council. Ethics approval was obtained from the University of Newcastle’s Human Research Ethics Committee (ID: H-2017–0026). The results from the study will be presented in several peer-reviewed publications, through conference presentations and via social media.

Implementing a protocol for a research impact assessment of the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery

BackgroundThere is growing recognition that the wider benefits of research (economic, social and health impacts) should be assessed and valued alongside traditional research performance metrics such as peer-reviewed papers. Translation of findings into policy and practice needs to accelerate and pathways to impact need to be better understood. This research protocol outlines a mixed methods study to apply the Framework to Assess the Impact from Translational health research (FAIT) to the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery (CRE-Stroke). FAIT is purpose-designed to encourage research translation and assess research impact but lacks validation.Methods/DesignPhase 1 involves application of the FAIT-modified programme logic model to each CRE-Stroke research stream including identifying process, output and impact metrics, as well as end users of the research. A scoping review will inform potential impacts anticipated from CRE-Stroke. In Phase 2, audit and feedback on achievements against plans will track and encourage research translation. Logic models will be updated to account for changes in the research pathways over time. In Phase 3, three proven methods for measuring research impact – Payback, economic assessment and narratives – will be applied to each research stream and the data triangulated and reported in Phase 4. The feasibility of applying FAIT will also be assessed as part of Phase 3.DiscussionUse of prospective, comprehensive research impact frameworks for large interdisciplinary programmes of research is rare. FAIT’s application to CRE-Stroke will provide opportunity for the impact of CRE-Stroke to be assessed and a range of impacts beyond standard academic achievements to be reliably reported. The feasibility of FAIT’s application will also be assessed and, if necessary, refined. The usefulness of FAIT for encouraging research translation will also be described and may prove useful for other programmes looking to implement a research impact framework.

Comparing and contrasting ‘innovation platforms’ with other forms of professional networks for strengthening primary healthcare systems for Indigenous Australians

Efforts to strengthen health systems require the engagement of diverse, multidisciplinary stakeholder networks. Networks provide a forum for experimentation and knowledge creation, information exchange and the spread of good ideas and practice. They might be useful in addressing complex issues or ‘wicked’ problems, the solutions to which go beyond the control and scope of any one agency. Innovation platforms are proposed as a novel type of network because of their diverse stakeholder composition and focus on problem solving within complex systems. Thus, they have potential applicability to health systems strengthening initiatives, even though they have been predominantly applied in the international agricultural development sector. In this paper, we compare and contrast the concept of innovation platforms with other types of networks that can be used in efforts to strengthen primary healthcare systems, such as communities of practice, practice-based research networks and quality improvement collaboratives. We reflect on our ongoing research programme that applies innovation platform concepts to drive large-scale quality improvement in primary healthcare for Aboriginal and Torres Strait Islander Australians and outline our plans for evaluation. Lessons from our experience will find resonance with others working on similar initiatives in global health.

Measuring research impact in medical research institutes: a qualitative study of the attitudes and opinions of Australian medical research institutes towards research impact assessment frameworks

BackgroundThe question of how to measure, assess and optimise the returns from investment in health and medical research (HMR) is a highly policy-relevant issue. Research Impact Assessment Frameworks (RIAFs) provide a conceptual measurement framework to assess the impact from HMR. The aims of this study were (1) to elicit the views of Medical Research Institutes (MRIs) regarding objectives, definitions, methods, barriers, potential scope and attitudes towards RIAFs, and (2) to investigate whether an assessment framework should represent a retrospective reflection of research impact or a prospective approach integrated into the research process. The wider objective was to inform the development of a draft RIAF for Australia’s MRIs.MethodsPurposive sampling to derive a heterogeneous sample of Australian MRIs was used alongside semi-structured interviews with senior executives responsible for research translation or senior researchers affected by research impact initiatives. Thematic analysis of the interview transcriptions using the framework approach was then performed.ResultsInterviews were conducted with senior representatives from 15 MRIs. Participants understood the need for greater research translation/impact, but varied in their comprehension and implementation of RIAFs. Common concerns included the time lag to the generation of societal impacts from basic or discovery science, and whether impact reflected a narrow commercialisation agenda. Broad support emerged for the use of metrics, case study and economic methods. Support was also provided for the rationale of both standardised and customised metrics. Engendering cultural change in the approach to research translation was acknowledged as both a barrier to greater impact and a critical objective for the assessment process. Participants perceived that the existing research environment incentivised the generation of academic publications and track records, and often conflicted with the generation of wider impacts. The potential to improve the speed of translation through prospective implementation of impact assessment was supported, albeit that the mechanism required development.ConclusionThe study found that the issues raised regarding research impact assessment are less about methods and metrics, and more about the research activities that the measurement of research translation and impact may or may not incentivise. Consequently, if impact assessment is to contribute to optimisation of the health gains from the public, corporate and philanthropic investment entrusted to the institutes, then further inquiry into how the assessment process may re-align research behaviour must be prioritised.

An ‘all teach, all learn’ approach to research capacity strengthening in Indigenous primary health care continuous quality improvement

In Australia, Indigenous people experience poor access to health care and the highest rates of morbidity and mortality of any population group. Despite modest improvements in recent years, concerns remains that Indigenous people have been over-researched without corresponding health improvements. Embedding Indigenous leadership, participation, and priorities in health research is an essential strategy for meaningful change for Indigenous people. To centralize Indigenous perspectives in research processes, a transformative shift away from traditional approaches that have benefited researchers and non-Indigenous agendas is required. This shift must involve concomitant strengthening of the research capacity of Indigenous and non-Indigenous researchers and research translators—all must teach and all must learn. However, there is limited evidence about how to strengthen systems and stakeholder capacity to participate in and lead continuous quality improvement (CQI) research in Indigenous primary health care, to the benefit of Indigenous people. This paper describes the collaborative development of, and principles underpinning, a research capacity strengthening (RCS) model in a national Indigenous primary health care CQI research network. The development process identified the need to address power imbalances, cultural contexts, relationships, systems requirements and existing knowledge, skills, and experience of all parties. Taking a strengths-based perspective, we harnessed existing knowledge, skills and experiences; hence our emphasis on capacity “strengthening”. New insights are provided into the complex processes of RCS within the context of CQI in Indigenous primary health care.

A mixed-methods study to explore opinions of research translation held by researchers working in a Centre of Research Excellence in Australia

Objective There is a growing need for researchers to demonstrate impact, which is reliant on successful research translation. The Australian National Health and Medical Research Council funded a Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery (CRE-Stroke) to enhance collaborations between researchers conducting different types of stroke rehabilitation research. The purpose of this study was to explore opinions about research translation held by CRE-Stroke researchers conducting preclinical and clinical research, in terms of scope, importance, responsibility and perceived skills and knowledge. Design Mixed-methods study, comprising a paper-based survey and semistructured interviews. Interview data were inductively coded and thematically analysed. Survey and interview data were compared and synthesised. Participants 55 (7 preclinical, 48 clinical) researchers attending a CRE-Stroke research forum completed a paper-based survey. Semistructured interviews with 22 CRE-Stroke (5 preclinical, 17 clinical) researchers were conducted. Results Research translation was described as translating to other research and translating to clinical practice and policy. Most researchers (n=54, 98%) reported that research translation was important, particularly in terms of generating research impact, but the most common sign of project completion reported by researchers (n=7, 100% preclinical; n=37, 77% clinical) was publication. Most researchers (preclinical n=4, 57%; clinical n=37, 77%) reported having responsibility for translating research, but less than half reported having the necessary skills (n=1, 14% preclinical; n=17, 35% clinical) and knowledge (n=3, 43% preclinical; n=19, 40% clinical). Differing opinions about who should be responsible for translating findings to clinical practice were expressed. Conclusions Stroke rehabilitation researchers appear confident to translate their research via the traditional mechanism of publications. To optimise impact, clarity is needed regarding who is best placed to translate research findings to clinical practice and policy. Education and skills development to apply broader translation processes are needed to maximise the use of research at all stages.