ORCID Profile
0000-0003-4509-5368
Current Organisations
University of Adelaide
,
Flinders University
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Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2005
DOI: 10.1097/01.SLA.0000154120.96169.99
Abstract: 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. 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. 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. 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.
Publisher: Springer Science and Business Media LLC
Date: 21-08-2012
Publisher: CSIRO Publishing
Date: 2013
DOI: 10.1071/AH13064
Abstract: 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. What is known about the topic? As a highly prevalent group of conditions that are likely to impact on health-related quality of life and are a common cause of severe long-term disability, musculoskeletal conditions place a significant burden on in iduals and the health system. However, far less is known about access and usage of musculoskeletal-related health services and programs in Australia. What does this paper add? As a result of analysing the characteristics of the overall BJP population, as well as phenotypes within it, a greater understanding of patterns of health service interactions, care pathways and opportunities for targeted improvements in delivery of care may be identified. The results emphasise that participants with BJP utilised the services of a narrow range of providers, which may have workforce implications for these sectors. The funding models for physiotherapists and chiropractors in Australia involve a mix of private and fees for service, which limits access to those who have private health insurance or can pay directly for these services. What are the implications for practitioners? These analyses indicate the importance of linking allied health professionals with general practice to manage BJP more efficiently. Alternative and appropriate care pathways need to be more strongly developed and identified for effective management of these conditions rather than relying on a traditional range of practitioners. Alternatively, greater ease of access to allied health practitioners may enable more effective treatment and improved quality of life for those with BJP. There is an urgent need to develop an effective population-based model of integrated care for BJP within regional Australia.
Publisher: Informa UK Limited
Date: 04-08-2023
Publisher: Wiley
Date: 19-06-2014
DOI: 10.1111/ANS.12726
Abstract: 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. Retrospective data on hospital separations in South Australia were analyzed using multiple regression to estimate the association between nine potentially modifiable co-morbidities and length of stay, post-operative complications and in-hospital mortality. After adjusting for primary diagnosis, age, gender and other potential confounders, significant increases in length of stay and complications were recorded for eight and six of the nine modifiable co-morbidities, respectively. As ex les, previous heart failure was associated with a 54% increase in length of stay and an odds ratio of 1.75 for complications. Asthma and chronic obstructive pulmonary disease was associated with a 38% increase in length of stay and an odds ratio of 1.64 for complications. A set of potentially modifiable co-morbidities is associated with a range of poorer post-operative outcomes, relative to patients without those co-morbidities. There is a clinical rationale that outcomes will be worse in the subset of patients for whom such co-morbidities are poorly controlled, and that timely intervention to improve control in the period prior to surgery will improve post-operative outcomes. Further research is required on post-operative outcomes for patients with and without controlled co-morbidities and on the effects of timely intervention to improve control prior to surgery.
Publisher: Wiley
Date: 26-04-2019
DOI: 10.1111/AJO.12821
Publisher: Wiley
Date: 02-11-2017
DOI: 10.1111/HEX.12422
Publisher: Springer Science and Business Media LLC
Date: 25-01-2017
Publisher: AMPCo
Date: 10-2017
DOI: 10.5694/MJA16.01178
Abstract: To compare the health and economic impacts of implementing efficacious treatment interventions with maintaining standard practice in maternal and perinatal health care. We identified randomised clinical trials (RCTs) in the Perinatal Society of Australia and New Zealand trials database that commenced recruitment during 2008 and had completed recruitment by 2015. Data from clinical trial registries and publications were collated to calculate the potential cost savings achievable by implementing efficacious treatment interventions. Projected net cost savings over 5 years. Twenty-three eligible RCTs covering a range of behavioural and clinical interventions were identified, of which six reported interventions superior to standard practice (four trials) or placebo (two). The outcomes (but not the costs) of 17 trials were excluded from analysis (no difference between intervention and comparator groups in seven trials, recruitment problems in six, findings not yet published in four). The total funding amount for the 23 trials was $20.3 million the potential cost savings over 5 years if the findings of the six trials reporting superior interventions were implemented was estimated to be $26.3 million if 10% of the eligible populations received the effective interventions, and $262.8 million with 100% implementation. Our retrospective analysis highlights the value of research in perinatal care and the importance of implementing positive findings for realising its value. Future trials in maternal and perinatal health care may provide significant returns on investment by informing clinical practice, improving patient outcomes and reducing health care costs.
Publisher: CSIRO Publishing
Date: 2011
DOI: 10.1071/AH10966
Abstract: Objective. Proposed Australian healthcare reforms describe a move towards partial Commonwealth funding of public hospitals, whereby hospitals will be paid an ‘efficient price’ for each separation, incorporating both the costs and benefits of services. This paper describes a potential approach to setting the efficient price using risk adjusted cost-effectiveness (RAC-E) analysis. Methods. RAC-E analysis uses a decision analytic framework to estimate lifetime costs and survival for in idual patients, which are standardised by comparing observed and expected values. Analysis of standardised costs and effects at different hospitals identifies efficient hospitals, from which efficient prices can be defined. Results. A RAC-E analysis of services for stroke patients at the four main public hospitals in South Australia demonstrates the need to account for costs and benefits in identifying efficient hospitals. The hospital with the best patient outcomes incurred additional costs relative to less effective hospitals. If an investment of AU$14 760 to gain an additional life year in stroke patients is deemed to be a cost-effective use of resources, then the most effective hospital is also the most efficient hospital. Conclusions. The applied RAC-E analysis demonstrates a framework for comparing the economic efficiency of care provided at different hospitals, which provides a basis for defining the efficient price and appropriate funding incentives to achieve better patient outcomes. What is known about the topic? The efficient price is a recently introduced concept used in the context of the recent healthcare reforms produced by the Australian government. The stated objective in setting nationally efficient prices for public hospital services is to ‘strike an appropriate balance between reasonable access, clinical safety, efficiency and fiscal considerations’. There has been no explicit discussion to date about specific processes for estimating the efficient price. What does this paper add? This paper introduces risk adjusted cost-effectiveness (RAC-E) analysis as a framework for identifying hospitals that achieve the best balance between costs and outcomes in the provision of services for specific diagnostic groups, and hence provides the basis for estimating efficient prices. What are the implications for practitioners? The efficient price will determine a significant proportion of funding for public hospitals. Practitioners need to be aware of the rationale and potential consequences of the efficient price, and to be sure that the method used to estimate the efficient price is robust and transparent.
Publisher: Wiley
Date: 30-04-2012
DOI: 10.1002/HEC.2828
Abstract: 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.
Publisher: Springer Science and Business Media LLC
Date: 09-12-2022
Publisher: Wiley
Date: 02-2003
Publisher: Elsevier BV
Date: 11-2018
DOI: 10.1016/J.RBMO.2018.08.024
Abstract: Does delaying IVF for 6 months in couples with unexplained infertility, compared with immediate IVF treatment, decrease the cost of IVF without compromising success rates? Decision modelling was used to evaluate the cost and outcomes of immediate IVF versus delayed IVF for a cohort of women aged <40 years suffering unexplained infertility. Australian data and costs were used in the analysis. For different age groups, three scenarios were tested where 10%, 50% and 90% of couples with unexplained infertility delayed IVF for 6 months if they had a good prognosis for natural conception. The study included a total of 8781 couples aged <40 years, diagnosed with unexplained infertility and who had IVF in 2013. The studied couples underwent 27,648 fresh and frozen embryo transfers, for an estimated total cost of $141 million. Potential out-of-pocket cost savings if 90% of couples delayed IVF ranged from $4.7 to $12.2 million, with Medicare cost savings of up to $15.1 million. The impact on the total pregnancy and live birth rates after 18 months was minimal. In couples with unexplained infertility and a good prognosis for natural conception, delaying IVF for 6 months could substantially decrease out-of-pocket costs without compromising pregnancy and live birth rates over an 18-month period.
Publisher: Springer Science and Business Media LLC
Date: 29-11-2012
DOI: 10.1007/S11657-012-0107-Y
Abstract: The aim of this study was to assess trends in hip fracture rates and outcomes following hospitalisation for hip fracture. Hip fracture admissions increased over the study period. Men fared worst in terms of higher absolute mortality. Refracture rates and male health outcomes require further attention. The aim of this study was to assess trends in hip fracture rates and outcomes following hospitalisation for hip fracture in South Australia (SA). Analysis of routinely collected, linked hospital separations data, of patients admitted to public and private hospitals in SA with a principal diagnosis of femoral neck fracture between July 2002 and June 2008 was done. Main outcome measures include number and rates of hospital admissions, 30-day in-hospital and 1-year mortality following a first hip fracture and subsequent event rates, by age and sex. Unadjusted hip fracture admissions increased in SA from 2002 to 2008 by 20 %, age-standardised (adjusted) admission rates increased overall (+5 %, p = 0.215) and significantly amongst males (+26 %, p = 0.001), while there was no change among women (−1 %, p = 0.763). Within 1 year of a hip fracture, 7 % had broken another bone (5 % had refractured a hip). At 1 year post-fracture, unadjusted mortality was consistently and considerably higher amongst men compared to women (33 versus 19 %, p < 0.001). Age-standardised mortality from admission to 1 year fell but not statistically significantly by 15 % in women (p = 0.131) and 8 % in men (p = 0.510). Women had a reduction in age-standardised in-hospital mortality over time (p = 0.048) there was a non-significant decline in men (p = 0.080). Hip fracture admissions in SA increased over the study period and this appears to be driven by an increase in admissions amongst men. Men fared worst in terms of higher absolute mortality. There is some evidence to suggest refracture rates and male health outcomes require further attention.
Publisher: Elsevier BV
Date: 12-2007
DOI: 10.1016/J.BURNS.2007.03.020
Abstract: To assess the safety and efficacy of bioengineered skin substitutes in comparison with biological skin replacements and/or standard dressing methods in the management of burns, through a systematic review of the literature. Literature databases were searched up to April 2006, identifying randomised controlled trials. Twenty randomised controlled trials were included in this review. The numerous sub-group analyses and the ersity of skin substitutes limited the ability to draw any conclusions from it. However, the evidence suggested that bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, Apligraf, autologous cultured skin, and allogeneic cultured skin, were at least as safe as biological skin replacements or topical agents/wound dressings. The safety of Integra could not be determined. For the management of partial thickness burns, the evidence suggested that bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, and allogeneic cultured skin, were at least as efficacious as topical agents/wound dressings or allograft. Apligraf combined with autograft was at least as efficacious as autograft alone. For the management of full thickness burns, the efficacy of autologous cultured skin could not be determined based on the available evidence. The efficacy of Integra could not be determined based on the available evidence. Additional methodologically rigorous randomised controlled trials with long-term follow-up would strengthen the evidence base for the use of bioengineered skin substitutes.
Publisher: Springer Science and Business Media LLC
Date: 15-10-2008
DOI: 10.1007/S00464-008-0182-8
Abstract: Laparoscopic ventral hernia repair may be an alternative to open mesh repair as it avoids a large abdominal incision, and thus potentially reduces pain and hospital stay. This review aimed to assess the safety and efficacy of laparoscopic ventral hernia repair in comparison with open ventral hernia repair. A systematic review was conducted, with comprehensive searches identifying six randomised controlled trials (RCTs) and eight nonrandomised comparative studies. The laparoscopic approach may have a lower recurrence rate than the open approach and required a shorter hospital stay. Five RCTs (Barbaros et al., Hernia 11:51-56, 2007 Misra et al., Surg Endosc 20:1839-1845, 2006 Navarra et al., Surg Laparosc Endosc Percutan Tech 17:86-90, 2007 Moreno-Egea et al., Arch Surg 137:266-1268, 2002 Carbajo et al., Surg Endosc 13:250-252, 1999) reported no conversion (0%) to open surgery, and four nonrandomised studies reported conversions to open surgery ranging from 0% to 14%. Open approach complications generally were wound related, whereas the laparoscopic approach reported both wound- and procedure-related complications and these appeared to be less frequently reported. Based on current evidence, the relative safety and efficacy of the laparoscopic approach in comparison with the open approach remains uncertain. The laparoscopic approach may be more suitable for straightforward hernias, with open repair reserved for the more complex hernias. Laparoscopic ventral hernia repair appears to be an acceptable alternative that can be offered by surgeons proficient in advanced laparoscopic techniques.
Publisher: Mark Allen Group
Date: 06-2006
DOI: 10.12968/JOWC.2006.15.6.26926
Abstract: Topical negative pressure (TNP) therapy was developed as an alternative to ‘standard’ forms of wound management and can be used for the early management of acute trauma or when more conventional methods have failed. Conventional methods of wound management include surgical debridement or the Healthpoint System (Healthpoint, Fort Worth, USA) which involves the use of three Food and Drug Administration (FDA)-approved gel products:
Publisher: Springer Science and Business Media LLC
Date: 25-10-2023
Publisher: Mark Allen Group
Date: 12-2008
DOI: 10.12968/JOWC.2008.17.12.31766
Abstract: This systematic review indicates that bioengineered skin substitutes with a dermal component may improve healing outcomes in diabetic foot ulcers and venous leg ulcers. However, better designed trials with longer follow-up periods are needed
Publisher: Elsevier BV
Date: 09-2018
DOI: 10.1016/J.FERTNSTERT.2018.05.001
Abstract: To determine the cost effectiveness of the use of oil-based versus water-based contrast in infertile women undergoing hysterosalpingography (HSG). Economic evaluation alongside a multicenter randomized trial. Hospitals. Infertile women with an ovulatory cycle, 18-39 years of age, low risk of tubal pathology. Use of oil-based versus water-based contrast during HSG. Costs per additional ongoing pregnancy and per live birth within 6 months of randomization, incremental cost-effective ratios (ICERs). A total of 1,119 women were randomized to HSG (oil-based contrast, n = 557 water-based contrast, n = 562). After HSG, most women had no additional treatment a minority had IUI or IVF. In the oil group, 39.7% women had an ongoing pregnancy within 6 months of randomization versus 29.1% women in the water group. There was a 10.7% increase in the live birth rate in the oil group. For ongoing pregnancy, the mean costs per couple were US$2,014 in the oil group and US$1,144 in the water group, with a corresponding ICER of US$8,198 per additional ongoing pregnancy. For live birth, the mean costs per couple were US$11,532 in the oil group and US$8,310 in the water group, with a corresponding ICER of US$30,112 per additional live birth. Hysterosalpingography with oil-based contrast results in higher 6-month ongoing pregnancy and live birth rate. If society is willing to pay US$8,198 for an additional ongoing pregnancy, HSG with oil-based contrast is a cost-effective strategy compared with HSG with water-based contrast for infertile, ovulatory women at low risk for tubal pathology. Dutch Trial Register, NTR 6577 (www.trialregister.nl).
Publisher: Wiley
Date: 06-2019
DOI: 10.1111/AJO.12975
Publisher: BMJ
Date: 12-2019
DOI: 10.1136/BMJOPEN-2019-033277
Abstract: Patients with comorbidities can be referred to a physician-led high-risk clinic for medical optimisation prior to elective surgery at the discretion of the surgical consultant, but the factors that influence this referral are not well understood. The aims of this study were to understand the factors that influence a surgeon’s decision to refer a patient to the clinic, and how the clinic impacts on the management of complex patients. Qualitative study using theoretical thematic analysis to analyse transcribed semi-structured interviews. Interviews were held in either the surgical consultant’s private office or a quiet office/room in the hospital ward. Seven surgical consultants who were eligible to refer patients to the clinic. When discussing the factors that influence a referral to the clinic, all participants initially described the optimisation of comorbidities and would then discuss with ex les the challenges with managing complex patients and communicating the risks involved with having surgery. When discussing the role of the clinic, two related subthemes were dominant and focused on the management of risk in complex patients. The participants valued the involvement of the clinic in the decision-making and communication of risks to the patient. The integration of the high-risk clinic in this study appears to offer additional value in supporting the decision-making process for the surgical team and patient beyond the clinical outcomes. The factors that influence a surgeon’s decision to refer a patient to the clinic appear to be driven by the aim to manage the uncertainty and risk to the patient regarding surgery and it was seen as a strategy for managing difficult and complex cases.
Publisher: Wiley
Date: 30-03-2016
DOI: 10.1111/JEP.12537
Abstract: 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. 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. 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. The application of alternative propensity-based approaches to a large s le of retrospective data, supplemented with a smaller s le 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.
Publisher: Wiley
Date: 06-09-2019
DOI: 10.1111/JEP.13282
Abstract: To summarize relevant international scientific evidence on strategies aimed at facilitating or improving health care practitioners' adoption of shared decision making in elective surgery. The review evaluated the effectiveness of these strategies and described the characteristics of identified strategies. A systematic search of the literature was conducted up to March 2019. The review included interventions that targeted patients, health care practitioners, or health systems/organizations. Main outcomes were measures of decision process and decision outcomes. Two independent reviewers conducted study selection, assessed methodological quality and extracted data. Fifteen randomized controlled trials, one pseudo-randomized controlled trial, and four quasi-experimental studies were included in this review. The heterogeneity of interventions and the variability of outcomes used to measure the impact of these interventions precluded meta-analysis. All of the interventions included an educational component regarding the medical condition of interest and available treatment options and a supportive component to encourage patients to ask questions and involve themselves in the decision making. Published evidence on shared decision-making interventions in elective surgery is most prevalent in the breast cancer/endocrine and urology specialties, with most studies targeting their shared decision-making interventions at the patient population. The use of multiple media components within an intervention including interactive video appeared to improve patient satisfaction with the shared decision-making process. The use of well-developed educational information provided through interactive multimedia, computer or DVD based, may enhance the decision-making process. The evidence suggests that such multimedia can be used prior to the surgical consultation, presenting medical and surgical information relevant to the upcoming consultation. A decision and communication aid also appears to be an effective method to support the surgeon in patient participation and involvement in the decision-making process.
Publisher: BMJ
Date: 12-2017
DOI: 10.1136/BMJOPEN-2017-018632
Abstract: Clinics have been established to provide preoperative medical consultations, and enable the anaesthetist and surgeon to deliver the best surgical outcome for patients. However, there is uncertainty regarding the effect of such clinics on surgical, in-hospital and long-term outcomes. A systematic review of the literature was conducted to determine the effectiveness of preoperative medical consultations by internal medicine physicians for patients listed for elective surgery. Systematic searches of MEDLINE, EMBASE, CINAHL, PubMed, Current Contents and the NHS Centre for Reviews and Dissemination were conducted up to 30 April 2017. Elective surgery. Randomised controlled trials and non-randomised comparative studies conducted in adults. Length of hospital stay, perioperative morbidity and mortality, costs and quality of life. The one randomised trial reported that preadmission preoperative assessment was more effective than the option of an inpatient medical assessment in reducing the frequency of unnecessary admissions with significantly fewer surgical cancellations following admission for surgery. A small reduction in length of stay in patients was also observed. The three non-randomised studies reported increased lengths of stay, costs and postoperative complications in patients who received preoperative assessment. The timing and delivery of the preoperative medical consultation in the intervention group differed across the included studies. Further research is required to inform the design and implementation of coordinated involvement of physicians and surgeons in the provision of care for high-risk surgical patients. A standardised approach to perioperative decision-making processes should be developed with a clear protocol or guideline for the assessment and management of surgical patients.
No related grants have been discovered for Clarabelle Pham.