Professor Leigh Kinsman

Background: Advances in stroke management such as acute stroke units and thrombolysis are not uniformly distributed throughout our population, with rural areas being relatively disadvantaged. It remains unclear, however, whether such disparities have led to corresponding differences in patient outcomes. Aims: To describe the regional differences in acute ischaemic stroke care and outcomes within the Australian state of Tasmania. Methods: A retrospective case note audit was used to assess the care and outcomes of 395 acute ischaemic stroke patients admitted to Tasmania's four major public hospitals. Sixteen care processes were recorded, which covered time-critical treatment, allied health interventions and secondary prevention. Outcome measures were assessed using 30-day mortality and discharge destination, both of which were analysed for differences between urban and rural hospitals using logistic regression. Results: No patients in rural hospitals were administered thrombolysis; these hospitals also did not have acute stroke units. With few exceptions, patients' access to the remaining care indicators was comparable between regions. After adjusting for confounders, there were no significant differences between regions in terms of 30-day mortality (odds ratio (OR) = 0.99, 95% confidence interval (CI) 0.46¿2.18) or discharge destination (OR = 1.24, 95% CI 0.81¿1.91). Conclusions: With the exception of acute stroke unit care and thrombolysis, acute ischaemic stroke care within Tasmania's urban and rural hospitals was broadly similar. No significant differences were found between regions in terms of patient outcomes. Future studies are encouraged to employ larger data sets, which capture a broader range of urban and rural sites and record patient outcomes at extended interval.

Background: Readmission rates following hospitalisation for COPD exacerbations are unacceptably high, and the contributing factors are poorly understood. Our objective was to summarise and evaluate the factors associated with 30-and 90-day all-cause readmission following hospitalisation for an exacerbation of COPD. Methods: We systematically searched electronic databases from inception to 5 November 2019. Data were extracted by two independent authors in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study quality was assessed using a modified version of the Newcastle¿Ottawa Scale. We synthesised a narrative from eligible studies and conducted a meta-analysis where this was possible using a random-effects model. Results: In total, 3533 abstracts were screened and 208 full-text manuscripts were reviewed. A total of 32 papers met the inclusion criteria, and 14 studies were included in the meta-analysis. The readmission rate ranged from 8.8¿26.0% at 30 days and from 17.5¿39.0% at 90 days. Our narrative synthesis showed that comorbidities, previous exacerbations and hospitalisations, and increased length of initial hospital stay were the major risk factors for readmission at 30 and 90 days. Pooled adjusted odds ratios (95% confidence intervals) revealed that heart failure (1.29 (1.22¿1.37)), renal failure (1.26 (1.19¿1.33)), depression (1.19 (1.05¿1.34)) and alcohol use (1.11 (1.07¿1.16)) were all associated with an increased risk of 30-day all-cause readmission, whereas being female was a protective factor (0.91 (0.88¿0.94)). Conclusions: Comorbidities, previous exacerbations and hospitalisation, and increased length of stay were significant risk factors for 30-and 90-day all-cause readmission after an index hospitalisation with an exacerbation of COPD.

Objective: To describe literature pertaining to urban-rural differences in both the quality of care and outcomes of acute stroke patients. Methods: We systematically searched CINAHL, PubMed, ProQuest Dissertations & Theses, and Scopus for published and unpublished literature until 9th December 2017. Studies were included if they compared the acute care provided to, or outcomes of, patients hospitalised for stroke in urban versus rural settings. Abstract, full-text review, and data extraction were conducted in duplicate. Findings are presented in the form of narrative syntheses. Results: A total of 28 studies were included in the review (16 on care, 12 on outcomes). With few exceptions, studies addressing the provision of care suggested that rural patients have less access to most aspects of acute stroke care. Studies reporting urban-rural differences in patient outcomes were inconsistent in their findings, however, few of these studies were primarily focused on the issue of urban-rural disparities. Overall, study findings did not appear to differ in line with study quality ratings, stroke subtypes included, or how inter-facility patient transfers were accounted for. Conclusions: There is convincing, albeit not unanimous, evidence to suggest that stroke patients in rural areas receive less acute care than their urban counterparts. Despite this, the available data and methodology have largely not been used to study urban-rural differences in patient outcomes. PROSPERO registration information: URL: https://www.crd.york.ac.uk/prospero. Unique identifier: CRD42017073262.

Objectives Junior doctors are frequently the first doctor to be called by a nurse to review patients whose clinical status has declined in hospital wards, yet little is known about how well prepared they are to deal with this situation. This paper aims to identify the factors that influence junior doctors¿ early recognition and management of patient deterioration in an acute ward settings. Method Integrative review methodology was used to allow for the inclusion of broad research designs, summarising current knowledge from existing research and identify gaps in the literature. Quantitative, qualitative and mixed method studies were included. An electronic database search including PubMed, Medline and Scopus was performed. Research articles, exploring junior doctors¿ skills specific to critically ill, or deteriorating patients, technical and non-technical skills and failure to rescue were included. Findings Thirty-three articles were included, of which eighteen were quantitative, six qualitative and nine mixed methods The majority of the studies, eighteen out of thirty-three, were from the United Kingdom. The evidence showed that the capacity for junior doctors to effectively deal with patient deterioration was influenced by: educational models that incorporated non-technical skills; the integration of high quality clinical simulation into education; and the level and type of supervision in the clinical environment. Conclusion The factors that influence junior doctors¿ capacity to recognise, respond and manage patient deterioration in an acute ward settings are complex. This review indicates that there is substantial room for improvement in junior doctors¿ capacity to deal with patient deterioration. Evidence suggests preparation of junior doctors in the recognition and management of the deteriorating patient is influenced by effective simulation education and clinical experiential exposure over time. More accessible supervision for junior doctors in acute wards is recommended to avert error and delays in the appropriate escalation of care in the deteriorating patient.

Background: The costs of investing in health care reform initiatives to improve quality and safety have been underreported and are often underestimated. This paper reports direct and indirect cost estimates for the initial phase of the province-wide implementation of Lean activities in Saskatchewan, Canada. Methods: In order to obtain detailed information about each type of Lean event, as well as the total number of corresponding Lean events, we used the Provincial Kaizen Promotion Office (PKPO) Kaizen database. While the indirect cost of Lean implementation has been estimated using the corresponding wage rate for the event participants, the direct cost has been estimated using the fees paid to the consultant and other relevant expenses. Results: The total cost for implementation of Lean over two years (2012-2014), including consultants and new hires, ranged from $44 million CAD to $49.6 million CAD, depending upon the assumptions used. Consultant costs accounted for close to 50% of the total. The estimated cost of Lean events alone ranged from $16 million CAD to $19.5 million CAD, with Rapid Process Improvement Workshops requiring the highest input of resources. Conclusions: Recognizing the substantial financial and human investments required to undertake reforms designed to improve quality and contain cost, policy makers must carefully consider whether and how these efforts result in the desired transformations. Evaluation of the outcomes of these investments must be part of the accountability framework, even prior to implementation.

Background: Chronic obstructive pulmonary disease (COPD) has substantial economic and human costs; it is expected to be the third leading cause of death worldwide by 2030. To minimize these costs high quality guidelines have been developed. However, guidelines alone rarely result in meaningful change. One method of integrating guidelines into practice is the use of clinical pathways (CPWs). CPWs bring available evidence to a range of healthcare professionals by detailing the essential steps in care and adapting guidelines to the local context. Methods/design: We are working with local stakeholders to develop CPWs for COPD with the aims of improving care while reducing utilization. The CPWs will employ several steps including: standardizing diagnostic training, unifying components of chronic disease care, coordinating education and reconditioning programs, and ensuring care uses best practices. Further, we have worked to identify evidence-informed implementation strategies which will be tailored to the local context. We will conduct a three-year research project using an interrupted time series (ITS) design in the form of a multiple baseline approach with control groups. The CPW will be implemented in two health regions (experimental groups) and two health regions will act as controls (control groups). The experimental and control groups will each contain an urban and rural health region. Primary outcomes for the study will be quality of care operationalized using hospital readmission rates and emergency department (ED) presentation rates. Secondary outcomes will be healthcare utilization and guideline adherence, operationalized using hospital admission rates, hospital length of stay and general practitioner (GP) visits. Results will be analyzed using segmented regression analysis. Discussion: Funding has been procured from multiple stakeholders. The project has been deemed exempt from ethics review as it is a quality improvement project. Intervention implementation is expected to begin in summer of 2017. This project is expected to improve quality of care and reduce healthcare utilization. In addition it will provide evidence on the effects of CPWs in both urban and rural settings. If the CPWs are found effective we will work with all stakeholders to implement similar CPWs in surrounding health regions. Trial registration: Clinicaltrials.gov (NCT03075709). Registered 8 March 2017.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess effects of Lean management in health care on patient, professional, and systems outcomes by addressing the following question. What are the effects of Lean management interventions in health care on patient outcomes, professional practice, and healthcare systems? What are the effects of Lean management interventions in health care on patient outcomes, professional practice, and healthcare systems? To answer the following questions in addressing secondary objectives: What are the effects of Lean management interventions in combination with other management systems (e.g. Six Sigma) on patient outcomes, professional practice, and healthcare systems (utilisation and access, adverse effects, cost)? Is the effectiveness of Lean interventions influenced by the setting (e.g. Emergency Department, Laboratory, Pharmacy) in which they are implemented? What are the effects of Lean management interventions in combination with other management systems (e.g. Six Sigma) on patient outcomes, professional practice, and healthcare systems (utilisation and access, adverse effects, cost)? Is the effectiveness of Lean interventions influenced by the setting (e.g. Emergency Department, Laboratory, Pharmacy) in which they are implemented?.

Objective: To measure the differences in the recording of risk factors and lifestyle advice between those at high risk of cardiovascular disease and those diagnosed with cardiovascular disease, and to identify the practice characteristics associated with such recording in rural primary care. Design: A cross-sectional observation study of 14 general practices. Medical records were audited to measure recording of risk factors and lifestyle advice for those at high risk of and those diagnosed with cardiovascular disease. Practice characteristics were collected, with logistic regression used to test for an association with the recording of risk factors. Setting: General practices in rural Australia. Participants: Each practice was asked to identify 20 patients; 10 at high risk and 10 diagnosed with cardiovascular disease. Main outcome measures: The recording of risk factors and lifestyle advice in patient records and practice characteristics. Results: 282 records were audited with 142 being high risk and 140 diagnosed with cardiovascular disease.Measures recorded significantly less in the high-risk group were: blood pressure (94% versus 99%; P=0.019); physical activity (24% versus 56%; P=0.000); dietary advice (32% versus 51%; P=0.001); and physical activity advice (34% versus 56%; P=0.000). Recording of risk factors was positively associated with practice involvement in quality improvement (P<0.001), continuing education (P<0.001), and greater percentage of general practitioners (P<0.05) and practice nurses (P<0.001). Conclusions: There is substantial room for enhanced cardiovascular disease prevention through rural primary care in Australia, particularly for high-risk patients. This study has demonstrated an association between practice factors (including targeted education, quality improvement activities and appropriate workforce) and improved preventive activities.

Rural primary care services have the potential to play a major role in reducing the gap in cardiovascular disease (CVD) outcomes between rural and metropolitan Australians, particularly in men at high risk of CVD. The aim of this study was to explore the self-reported behaviours and satisfaction with their general practice/practitioner of men at high risk of CVD, and attitudes of rural primary care clinicians regarding the role of primary care in CVD prevention. This observational research was addressed through survey questionnaires with rural men at high risk of CVD and semi-structured interviews with rural primary care clinicians. Fourteen rural primary care practices from towns with populations less than 25000 participated. One hundred and fifty-eight high-risk men completed the questionnaire. Their responses demonstrated poorly controlled risk factors despite a willingness to change. Alternatively, rural primary care clinicians (n=20) reported that patients were unlikely to change and that illness-based funding models inhibited cardiovascular preventive activities. Australians living in rural areas have worse CVD outcomes. In addition, there is a disparity in the assumptions of health providers and male patients at high risk of CVD in rural areas. This necessitates innovative rural primary care models that include a blended payment system that incentivises or funds preventive care alongside an emphasis on lifestyle advice, as well as an explicit strategy to influence clinician and patient behaviour to help address the disparity.

Inadequate management of deteriorating patients is of international concern. In order to tackle this issue there has been an increasing effort to upskill nursing and medical staff (Australian Commission on Safety and Quality in Healthcare, 2012).

The Saskatchewan Ministry of Health has committed to a multi-million dollar investment toward the implementation of Lean methodology across the province's healthcare system. Originating as a production line discipline (the Toyota Production System), Lean has evolved to encompass process improvements including inventory management, waste reduction and quality improvement techniques. With an initial focus on leadership, strategic alignment, training and the creation of a supportive infrastructure (Lean promotion offices), the goal in Saskatchewan is a whole health system transformation that produces "better health, better value, better care, and better teams." Given the scope and scale of the initiative and the commitment of resources, it is vital that a comprehensive, longitudinal evaluation plan be implemented to support ongoing decision-making and program design. The nature of the initiative also offers a unique opportunity to contribute to health quality improvement science by advancing our understanding of the implementation and evaluation of complex, large-scale healthcare interventions. The purpose of this article is to summarize the background to Lean in Saskatchewan and the proposed evaluation methods.

The aim of this study was a rigorous evaluation of a clinical pathway (CP) in patients who underwent a radical laparoscopic prostatectomy (RLP). The study was performed at a German university hospital. The Department of Urology has considerable expertise and performs more than 200 RLP per year. The CP for 'RLP' was developed based on the best available evidence and introduced in July 2003. It was composed of six modules, and in each module standardized recommendations for clinical examination, therapy and outcome measurement were given. An interrupted time series design with multiple linear regression models was used to measure the effects of a CP for 'RLP' on length of hospital stay, and durations of operation and anaesthesia before and after implementation. ¿ tests were used to compare the number of patients admitted to intensive care unit, the number requiring re-operation during admission, the number requiring transfusion(s) of blood products and 30-d readmission rates. A total of 254 patients were analysed. A significant reduction in operation time and admission to intensive care but also a significant increase of patients readmitted to the hospital after the implementation of a CP was observed. Inconclusive results always warrant careful exploration, and measures on CP uptake should always be used to evaluate the success or failure of the implementation strategy. © 2014 John Wiley & Sons Ltd. 2

Background: Lean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits. It emphasizes the consideration of the customer's needs, employee involvement and continuous improvement. Research on the application and implementation of lean principles in health care has been limited. Methods: This is a protocol for a systematic review, following the Cochrane Effective Practice and Organisation of Care (EPOC) methodology. The review aims to document, catalogue and synthesize the existing literature on the effects of lean implementation in health care settings especially the potential effects on professional practice and health care outcomes. We have developed a Medline keyword search strategy, and this focused strategy will be translated into other databases. All search strategies will be provided in the review. The method proposed by the Cochrane EPOC group regarding randomized study designs, non-randomised controlled trials controlled before and after studies and interrupted time series will be followed. In addition, we will also include cohort, case-control studies, and relevant non-comparative publications such as case reports. We will categorize and analyse the review findings according to the study design employed, the study quality (low- versus high-quality studies) and the reported types of implementation in the primary studies. We will present the results of studies in a tabular form. Discussion: Overall, the systematic review aims to identify, assess and synthesize the evidence to underpin the implementation of lean activities in health care settings as defined in this protocol. As a result, the review will provide an evidence base for the effectiveness of lean and implementation methodologies reported in health care.

Evidence shows the management of deteriorating patients needs to be improved, particularly in midwifery care. In a series of three simulation-based studies in Australia we examined qualified nurses', student nurses' and midwives' ability to manage patient deterioration. Nurses' knowledge levels were acceptable but their skill performance was low and there was a gap between the theory and practice they had experienced. In these high-pressure situations, demographic factors (including educational level) had no impact on their performance, which suggests they need repetitive "high-stakes" simulation, improved feedback mechanisms and enhanced educational processes.