Novel Tool to Monitor Adherence to Oral Oncolytics: A Pilot Study.

PURPOSE: Nonadherence is a significant issue in cancer care, especially as more oral therapies become available. Measuring and optimizing adherence to such therapies is challenging. In this study, we tested a novel technology that records real-time medication-taking behavior from a smart prescription bottle and can communicate with patients via text message to intervene in cases of nonadherence. METHODS: We conducted a 28-patient pilot study to assess the feasibility of this technology in measuring and improving adherence in patients taking capecitabine, an oral chemotherapy agent with a complex, cyclical regimen. The study had a preintervention stage, during which patients were monitored, and an intervention stage, during which the text messaging intervention was enabled. RESULTS: During preintervention, patients had an average self-adherence of 89%, and during post intervention, they had an average adherence of 90%. We defined three categories of patients by change in adherence: category 1 (> 8%), category 2 (-8% to 8%), and category 3 (< -8%). Patients in category 1 tended to live in regions with lower average household income (mean = $58,937 in US dollars [USD]) than those in category 2 (mean = $77,482 USD) and category 3 (mean = $90,972 USD). Of poststudy survey respondents, most indicated that they would want to continue using this technology and that they would recommend it to others. CONCLUSION: This novel technology is able to monitor, measure, and intervene for patients taking capecitabine in real time. Adherence overall was high, and some patients appeared to benefit more from text-message interventions. Future work should focus on patients deemed high risk for nonadherence.

Academic achievement and productivity losses associated with speech, language and communication needs.

BACKGROUND: Childhood speech, language and communication needs (SLCN) impose a significant burden on individuals, families and society. There are explicit costs related to increased health utilization and expenditure. Additionally, there may be indirect costs associated with a child's employment prospects in the long term because of the child's low literacy and numeracy, which in turn affects adult labour force participation (LFP). Several reviews have identified that there is paucity of published evidence on the costs of SLCN. Motivated by broad policy implications, and the lack of prior research in this area, this paper calculates the indirect costs and workplace productivity losses of children with SLCN. AIMS: To estimate the indirect costs of SLCN associated with a child's reduced long-term productivity. METHODS & PROCEDURES: Using 12 years of data from a longitudinal study of Australian children, we employed a panel fixed-effects model to estimate academic achievement at 14-15 years of age. Using these estimates, we employed a human capital approach (HCA) to estimate the projected LFP for children with SLCN, measured by workforce participation and foregone wages. LFP is estimated by extrapolating a child's academic achievement at 14-15 years of age to adulthood outcomes. OUTCOMES & RESULTS: The results showed that a 1 SD (standard deviation) decrease in SLCN is equivalent to 0.19 (95% confidence interval (CI) = 0.09, 0.30) SD decrease in academic achievement at 14-15 years, 0.79% (95% CI = 0.37, 1.21) decrease in work participation and A$453 (95% CI = A$207, A$674) per annum in lost wages. The average work participation penalty across all level of SLCN (-3, -2, -1) is A$628 (95% CI = A$236, A$894) per person per year. Based on the prevalence of 8.3% from our sample, this equates to lifetime costs of A$21.677 billion (US$14.28 billion, €13.08 billion, £11.66 billion) for children with SLCN in Australia. Speech pathology treatment appears to have a positive impact on work participation and wages. On average A$355 (95% CI = A$346, A$355) per person per year could be saved through treatment or identification (the difference in lost wages for children with and without speech pathology treatment at each SLCN level (-1, -2 ,-3) calculated as a weighted average). This equates to lifetime savings of A$5.22 billion (US$3.44 billion, €3.15 billion, £2.81 billion) for children with SLCN in Australia. CONCLUSIONS & IMPLICATIONS: Overall, the findings showed that SLCN are associated with increased indirect costs through reduced workforce participation. The evidence from this study can be used to inform policies on the societal costs of SLCN. What this paper adds What is already known on this subject Childhood SLCN impose significant burden on individuals, families and society. There are explicit costs related to increased health utilization and expenditure. Additionally, there may be indirect costs associated with a child's employment prospects in the long term because of the child's low literacy and numeracy, which in turn affects adult LFP. Several reviews have identified that there is paucity of published evidence on the costs of SLCN. Motivated by broad policy implications, and the lack of prior research in this area, this paper calculates the indirect costs and workplace productivity losses of children with SLCN. What this paper adds to existing knowledge This study estimates the academic achievement and indirect costs of SLCN associated with a child's reduced long-term productivity. Using 12 years of data from a longitudinal study of Australian children, we employed a panel fixed-effects model to estimate academic achievement at 14-15 years of age. Using these estimates, we used a human capital approach to estimate the projected LFP for children with SLCN, measured by workforce participation and foregone wages. LFP is estimated by extrapolating a child's academic achievement at 14-15 years of age to adulthood outcomes. What are the potential or actual clinical implications of this work? SLCN are associated with increased indirect costs through reduced workforce participation. The evidence from this study provides one of the first indirect cost estimates of how SLCN impacts LFP through educational achievement. Early identification, intervention and screening for SLCN may be useful offsets to reduce the economic effects identified here.

Health and wellbeing of people with intellectual disability in New South Wales, Australia: a data linkage cohort.

PURPOSE: People with intellectual disability (ID) experience high rates of physical and mental health problems, while access to appropriate healthcare is often poor. This cohort was established to develop an epidemiological profile related to the health, health service use, disability services, mortality and corrective services records of people with ID. PARTICIPANTS: The cohort contains 92 542 people with ID (40% females) with a median age of 23 years (IQR: 12-43 years) and 2 004 475 people with a neuropsychiatric or developmental disorder diagnosis (50% females) with a median age of 51 years (IQR: 29-73 years) from New South Wales, Australia. The whole sample contains records for 2 097 017 individuals with most data sets spanning financial years 1 July 2001 to 30 June 2016. A wide range of data from linked population data sets are included in the areas of disability, health, corrective services and targeted specialist support services in public schools, Public Guardian and Ombudsman services. FINDINGS TO DATE: This study includes one of the largest cohorts of people with ID internationally. Our data have shown that the presence of ID is significantly associated with emergency department presentations and psychiatric readmissions after the first psychiatric admission based on a subcohort of people with a psychiatric admission. Adults with ID experience premature mortality and over-representation of potentially avoidable deaths compared with the general population. FUTURE PLANS: Within the health service system, we will examine different components, that is, inpatient, emergency adult services, children and younger people services and costs associated with healthcare as well as mortality, cause and predictors of death. The neuropsychiatric and developmental disorders comparison cohort allows comparisons of the physical health, mental health and service use profiles of people with ID and those with other neuropsychiatric disorders.

Health care use and costs at the end of life: a comparison of elderly Australian decedents with and without a cancer history.

BACKGROUND: There is limited population-level research on end-of-life care in Australia that considers health care use and costs across hospital and community sectors. The aim of this study was to quantify health care use and costs in the last 6 months of life in a cohort of elderly Australian decedents and to examine the factors associated with end-of-life resource use and costs. METHODS: A retrospective cohort study using routinely collected health data from Australian Government Department of Veterans' Affairs clients. The study included two cohorts of elderly Australians who died between 2005 and 2009; one cohort with a recorded cancer diagnosis and a comparison cohort with no evidence of a cancer history. We examined hospitalisations, emergency department (ED) visits, prescription drugs, clinician visits, pathology, and procedures and associated costs in the last 6 months of life. We used negative binominal regression to explore factors associated with health service use and costs. RESULTS: The cancer cohort had significantly higher rates of health service use and 27% higher total health care costs than the comparison cohort; in both cohorts, costs were driven primarily by hospitalisations. Older age was associated with lower costs and those who died in residential aged care incurred half the costs of those who died in hospital. CONCLUSIONS: The results suggest differences in end-of-life care pathways dependent on patient factors, with younger, community-dwelling patients and those with a history of cancer incurring significantly greater costs. There is a need to examine whether the investment in end-of-life care meets patient and societal needs.

Cohort profile: a data linkage cohort to examine health service profiles of people with intellectual disability in New South Wales, Australia.

PURPOSE: People with intellectual disability are a minority group who experience poorer physical and mental health than the general population and have difficulty accessing healthcare services. There is lack of knowledge about healthcare service needs and gaps experienced by people with intellectual disability. This study aims to interrogate a large linked administrative data set containing hospital admissions, presentations to emergency departments (ED) and mortality data to provide evidence to inform the development of improved health and mental health services for this population. PARTICIPANTS: A retrospective cohort of people with intellectual disability (n=51 452) from New South Wales (NSW), Australia, to explore health and mental health profiles, mortality, pattern of health service use and associated costs between 2005 and 2013. The cohort is drawn from: the Disability Services Minimum Data Set; Admitted Patients Data Collection; Emergency Department Data Collection, Australian Bureau of Statistics Death Registry and Registry of Births, Deaths and Marriages. Mental health service usage among those with intellectual disability will be compared to a cohort of people who used mental health services (n=1 073 139) and service usage other than for mental health will be compared with published data from the general population. FINDINGS TO DATE: The median age of the cohort was 24 at the time of the last hospital admission and 21 at the last ED presentation. The cohort has a higher proportion of men than women and accounts for 0.6% of the NSW population in 2011. Over 70% had up to 5 ED presentations and hospitalisations between 2005 and 2012. A high proportion of people with intellectual disability live in the most disadvantaged neighbourhoods. FUTURE PLANS: Results will be used to inform the development of more responsive healthcare, including improved interactions between health, social and disability supports. More generally, the results will assist the development of more inclusive policy frameworks for people with intellectual disability.

The impact of childhood language difficulties on healthcare costs from 4 to 13 years: Australian longitudinal study.

PURPOSE: This study investigated the relationship between children's language difficulties and health care costs using the 2004-2012 Longitudinal Study of Australian Children (LSAC). METHOD: Language difficulties were defined as scores ≤1.25SD below the standardised mean on measures of directly assessed receptive vocabulary (4-9 years) and teacher-reported language and literacy (10-13 years). Participant data were individually linked to administrative data, which were sourced from Australia's universal subsidised healthcare scheme (Medicare). RESULT: It was found that healthcare costs over each 2-year age band were higher for children with language difficulties than without in the 4-5-year-age bracket (mean difference = AU$357, 95%CI $59, $659), in the 6-7-year-age bracket (mean difference = AU$602, 95%CI $136, $1068) and in the 10-11-year-age bracket (mean difference = AU$504, 95%CI $153, $854). Out-of-pocket costs, that is the portion of healthcare costs paid for by the family, were also higher for children with than without language difficulties in the 4-5-year-age bracket (mean difference = AU$123, 95%CI $46, $199), in the 6-7-year-age bracket (mean difference = AU$176, 95%CI $74,278) and in the 10-11-year-age bracket (mean difference = AU$79, 95%CI $6, $152). Medical services accounted for 97% of total healthcare cost differences. CONCLUSION: Overall the findings from this study suggest that language difficulties are associated with increased healthcare costs at key developmental milestones, notably early childhood and as a child approaches the teenage years.

Estimating prevalence of drug and alcohol presentations to hospital emergency departments in NSW, Australia: impact of hospital consultation liaison services.

The impact of drug and alcohol misuse has been the subject of widespread media discussion in the past year, particularly in the context of restricted alcohol trading hours in an effort to reduce alcohol-fuelled violence. A recent study evaluating NSW Health's drug and alcohol consultation liaison (CL) services1 demonstrates how pervasive drug and alcohol problems are, and the impact they have on the health system. This paper highlights how expanding CL services to fill current unmet need could deliver a range of benefits to patients and hospitals.

Evaluating the Impact of Hospital Based Drug and Alcohol Consultation Liaison Services.

Consultation liaison (CL) services provide direct access to specialist services for support, treatment advice and assistance with the management of a given condition. Alcohol and other drugs (AOD) CL services aim to improve identification and treatment of patients with AOD morbidity. Our objective was to evaluate the costs and consequences of AOD CL services in hospitals in New South Wales, Australia. Patients were surveyed at eight hospitals and problematic AOD use was identified using the Alcohol, Smoking and Substance Involvement Screening Test (n=1615). For consenting participants, medical record data were obtained from 18 months pre- to 12 months post-survey. We used interrupted time series analyses to compare utilization and costs for patients with and without AOD problems and changes over time between those who received AOD CL and similar patients. Approximately 35% of patients surveyed had AOD problems (excluding tobacco) with 7% requiring intensive treatment. Only 24% of patients requiring intensive treatment were treated by AOD CL. Those treated had relative improvements over time in the cost of presentations to emergency departments, emergency admission performance and increased uptake of appropriate pharmaceuticals. The estimated net benefit of AOD CL services was at least AUD$100,000 savings per hospital per year. Expanding AOD CL services to address current unmet need may lead to even greater cost savings for hospitals.

Health service use and costs in the last 6 months of life in elderly decedents with a history of cancer: a comprehensive analysis from a health payer perspective.

BACKGROUND: There is growing interest in end-of-life care in cancer patients. We aim to characterise health service use and costs in decedents with cancer history and examine factors associated with resource use and costs at life's end. METHODS: We used routinely collected claims data to quantify health service use and associated costs in two cohorts of elderly Australians diagnosed with cancer: one cohort died from cancer (n=4271) and the other from non-cancer causes (n=3072). We used negative binomial regression to examine the factors associated with these outcomes. RESULTS: Those who died from cancer had significantly higher rates of hospitalisations and medicine use but lower rates of emergency department use than those who died from non-cancer causes. Overall health care costs were significantly higher in those who died from cancer than those dying from other causes; and 40% of costs were expended in the last month of life. CONCLUSIONS: We analysed health services use and costs from a payer perspective, and highlight important differences in patterns of care by cause of death in patients with a cancer history. In particular, there are growing numbers of highly complex patients approaching the end of life and the heterogeneity of these populations may present challenges for effective health service delivery.

Satisfaction with nursing education, job satisfaction, and work intentions of new graduate nurses.

BACKGROUND AND OBJECTIVE: In the context of predictions of future shortages of nurses, retaining new graduate nurses in the nursing workforce is essential to ensure sufficient nurses in the future. This paper investigates the links between satisfaction with nursing education and job satisfaction, and job dissatisfaction and intentions to leave a nursing job. DESIGN AND DATA SOURCES: It uses survey data from a cohort study of nursing students recruited through two Australian universities and followed after graduation and workforce entry. METHOD: Structural equation modeling (SEM) was used to simultaneously estimate the impact of educational satisfaction (work preparation component) on job satisfaction and the impact of job satisfaction on the expectation of leaving the current job. RESULTS: Two job satisfaction sub-scales were identified: 1) work environment satisfaction and 2) work hours and wages satisfaction. Work preparation satisfaction was significantly and positively associated with both job satisfaction scales but only work environment satisfaction was significantly associated with the expectation to stay in the job; a one standard deviation increase in work environment satisfaction was associated with a 13.5 percentage point reduction in the probability of expecting to leave. The estimated effect of satisfaction with education on expecting to leave, occurring indirectly through job satisfaction, was small (reducing the probability by less than 3 percentage points for a 1 point increase in work preparation satisfaction). Participating in a graduate transition program had the largest effect, reducing the probability of expecting to leave by 26 percentage points, on average. CONCLUSIONS: The study results suggest policies which focus on improving satisfaction with the work environment would be more effective at retaining nurses early in their career than improvements to conditions such as work hours and wages. Investment in new graduate transition programs would potentially have the largest impact on retention.

The hidden costs of drug and alcohol use in hospital emergency departments.

INTRODUCTION AND AIMS: This study estimates the burden of drug and alcohol morbidity on hospitals in New South Wales (NSW) by observing a multi-site collective sample utilising survey information and data linkage. Specifically we aimed to determine the prevalence of alcohol and other drug (AOD) problems and to estimate patterns of utilisation of hospital services, costs of presentations, and admissions for patients with AOD problems. DESIGN AND METHODS: Patients were recruited from eight NSW public hospitals presenting to the hospital emergency department over a 10 day period. Participants completed a self-administered survey with demographic characteristics and questions about substance use. More than two-thirds (68%) of participants consented to provide access to their NSW Health medical data for a period spanning 2.5 years. RESULTS: One-third (35%) of the total sample were identified as having problematic AOD use with one in five of these patients requiring a high level of intervention. Those patients requiring a high level of intervention present more often and cost more per presentation. If admitted they were more likely to have longer stays and were also more likely to be admitted to a psychiatric ward and have a longer stay in the ward. DISCUSSION: This study demonstrates a need for AOD interventions in the emergency department setting, both because it represents an opportunity for intervention in a population in which problems with substance use is highly prevalent, and because there is evidence that AOD imposes additional costs on the health system. [Butler K, Reeve R, Arora S, Viney R, Goodall S, van Gool K, Burns L. The hidden costs of drug and alcohol use in hospital emergency departments. Drug Alcohol Rev 2016;35:359-366].

Is accreditation linked to hospital infection rates? A 4-year, data linkage study of Staphylococcus aureus rates and accreditation scores in 77 Australian acute hospitals.

OBJECTIVES: To test our hypothesis that hospitals with higher accreditation scores, specifically in infection control, would be associated with lower Staphylococcus aureus bacteraemia (SAB) rates. DESIGN: A retrospective cohort study. SETTING AND PARTICIPANTS: Acute public hospitals (n = 77) in New South Wales, Australia, with reported SAB rates, results from two accreditation surveys and results from at least four hand hygiene audits. METHODS: We linked three separate data sets comprising SAB rates, accreditation scores and hand hygiene rates. SAB rates were regressed against accreditation scores, hand hygiene audit rates and hospital demographics using a generalized linear model to account for the non-linear nature of our outcome variable. RESULTS: Significant (P < 0.05) findings included the following: SAB rates across all hospitals fell from 1.34 per 10 000 bed days in 2009 to 0.77 per 10 000 bed days in 2012; mean SAB rates in small hospitals (0.62/10 000 bed days) over the study period were lower than those for principal referral hospitals (1.52/10 000 bed days); smaller hospitals with higher accreditation scores had lower SAB rates, but larger hospitals with higher overall accreditation scores had higher SAB rates, although the effect size was small (<2%). CONCLUSIONS: There is a strong evidence base for using SAB rates to measure the impact of infection control programs that are assessed during accreditation. However, there is less evidence to support whether accreditation scores accurately reflect implementation of the infection control accreditation standards. This impacts identification of indicators to measure patient safety and quality of care, especially in ensuring these are appropriate across a range of hospital size and activities.

Resource use, costs and quality of end-of-life care: observations in a cohort of elderly Australian cancer decedents.

BACKGROUND: The last year of life is one of the most resource-intensive periods for people with cancer. Very little population-based research has been conducted on end-of-life cancer care in the Australian health care setting. The objective of this program is to undertake a series of observational studies examining resource use, costs and quality of end-of-life care in a cohort of elderly cancer decedents using linked, routinely collected data. METHODS/DESIGN: This study forms part of an ongoing cancer health services research program. The cohorts for the end-of-life research program comprise Australian Government Department of Veterans' Affairs decedents with full health care entitlements, residing in NSW for the last 18 months of life and dying between 2005 and 2009. We used cancer and death registry data to identify our decedent cohorts and their causes of death. The study population includes 9,862 decedents with a cancer history and 15,483 decedents without a cancer history. The median age at death is 86 and 87 years in the cancer and non-cancer cohorts, respectively. We will examine resource use and associated costs in the last 6 months of life using linked claims data to report on health service use, hospitalizations, emergency department visits and medicines use. We will use best practice methods to examine the nature and extent of resource use, costs and quality of care based on previously published indicators. We will also examine factors associated with these outcomes. DISCUSSION: This will be the first Australian research program and among the first internationally to combine routinely collected data from primary care and hospital-based care to examine comprehensively end-of-life care in the elderly. The research program has high translational value, as there is limited evidence about the nature and quality of care in the Australian end-of-life setting.

Improving clinician-carer communication for safer hospital care: a study of the 'TOP 5' strategy in patients with dementia.

OBJECTIVE: To examine the impact of implementing a clinician-carer communication tool for hospitalized patients with dementia. DESIGN: Surveys were conducted with clinicians and carers about perceptions and experiences. Implementation process and costs were explored through surveys of local staff. Time series analysis was conducted on incident-reported falls, usage of non-regular anti-psychotics and one-to-one nursing. SETTING: Twenty-one hospitals in Australia. PARTICIPANTS: Surveys were returned by 798 clinicians, 240 carers and 21 local liaison staff involved in implementation. INTERVENTION: Implementation of a communication tool over 12 months. MAIN OUTCOME MEASURES: The process of implementation was documented. Outcome measures included clinician and carer perceptions, safety indicators (incident-reported falls and usage of non-regular anti-psychotics), resource use and costs. RESULTS: Clinicians and carers reported high levels of acceptability and perceived benefits for patients. Clinicians rated confidence in caring for patients with dementia as being significantly higher after the introduction of TOP 5, (M = 2.93, SD = 0.65), than prior to TOP 5 (M = 2.74, SD = 0.75); F(1,712) = 11.21, P < 0.05. When analysed together, there was no change in incident-reported falls across all hospitals. At one hospital with a matched control ward, an average of 6.85 fewer falls incidents per month occurred in the intervention ward compared with the matched control ward (B = -6.85, P < 0.05). CONCLUSIONS: Our findings indicate that the use of a simple, low-cost communication strategy for patient care is associated with improvements in clinician and carer experience with potential implications for patient safety. Minimally, TOP 5 represents 'good practice' with a low risk of harm for patients.

Factors that drive the gap in diabetes rates between Aboriginal and non-Aboriginal people in non-remote NSW.

OBJECTIVE: To identify factors underpinning the gap in diabetes rates between Aboriginal and non-Aboriginal people in non-remote NSW. This will indicate appropriate target areas for policy and for monitoring progress towards reducing the gap. METHODS: Data from the 2004-05 National Health Survey and National Aboriginal and Torres Strait Islander Health Survey were used to estimate differences in self-reported diabetes rates and risk/prevention factors between Aboriginal and non-Aboriginal people in non-remote NSW. Logistic regression models were used to investigate the contribution of each factor to predicting the probability of diabetes. RESULTS: Risk factors for diabetes are more prevalent and diabetes rates 2.5 to 4 times higher in Aboriginal compared to non-Aboriginal adults in non-remote NSW. The odds of (known) diabetes for both groups are significantly higher for older people, those with low levels of education and those who are overweight or obese. In the Aboriginal sample, the odds of diabetes are significantly higher for people reporting forced removal of their relatives. CONCLUSIONS: Differences in BMI and education appear to be driving the diabetes gap, together with onset at younger ages in the Aboriginal population. Psychological distress, indicated by removal of relatives, may contribute to increased risk of diabetes in the Aboriginal population. IMPLICATIONS: The results imply that improved nutrition and exercise, capacity to access and act upon health care information and early intervention are required to reduce the diabetes gap. Current strategies appear to be appropriately aligned with the evidence; however, further research is required to determine whether implementation methods are effective.