Use of telehealth in the provision of after-hours palliative care services in rural and remote Australia: A scoping review protocol

Introduction After-hours services are essential in ensuring patients with life limiting illness and their caregivers are supported to enable continuity of care. Telehealth is a valuable approach to meeting after-hours support needs of people living with life-limiting illness, their families, and caregivers in rural and remote communities. It is important to explore the provision of after-hours palliative care services using telehealth to understand the reach of these services in rural and remote Australia. A preliminary search of databases failed to reveal any scoping or systematic reviews of telehealth in after-hours palliative care services in rural or remote Australia. Aim To review and map the available evidence about the use of telehealth in providing after-hours palliative care services in Australian rural and remote communities. Methods The proposed scoping review will be conducted using the Arksey and O’Malley methodological framework and in accordance with the Joanna Briggs Institute methodology for scoping reviews. The reporting of the scoping review will be guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). This review will consider research and evaluation of after-hours services using telehealth for palliative care stakeholders in rural and remote Australia. Peer reviewed studies and grey literature published in English from 2000 to May 2021 will be included. Scopus, Web of Science, CINAHL Complete, Embase via Ovid, PsycINFO via Ovid, Emcare via Ovid, Medline via Ovid, and grey literature will be searched for relevant articles. Titles and abstracts will be screened by two independent reviewers for assessment against the inclusion criteria. Data will be extracted and analysed by two reviewers using an adapted data extraction tool and thematic analysis techniques. Diagrams, tables, and summary narratives will be used to map, summarise and thematically group the characteristics of palliative care telehealth services in rural and remote Australia, including stakeholders’ perceptions and benefits and challenges of the services.

Skill reconsolidation does not operate at a rapid micro-timescale level

Abundant evidence shows that consolidated memories are susceptible to modifications following their reactivation through reconsolidation. Processes of memory consolidation and reconsolidation have been commonly documented after hours or days. Motivated by studies showing rapid consolidation in early stages of skill acquisition, here we asked whether skill memories are susceptible to modifications through rapid reconsolidation, even at initial stages of learning. In a set of experiments, we collected crowdsourced online motor sequence data to test whether post-reactivation interference and enhancement occur through rapid reconsolidation. Results indicate that memories forming during early learning are not susceptible to interference nor to enhancement within a rapid reconsolidation time window, relative to control conditions. This set of evidence suggests that memory reconsolidation might be dependent on consolidation at the macro-timescale level, requiring hours or days to occur.

Rural Patients’ Perceptions of Their Potentially Preventable Hospitalisation: A Qualitative Study

Potentially preventable hospitalisations (PPHs) occur when patients receive hospital care for a condition that could have been more appropriately managed in the primary healthcare setting. It is anticipated that the causes of PPHs in rural populations may differ from those in urban populations; however, this is understudied. Semi-structured interviews with 10 rural Australian patients enabled them to describe their recent PPH experience. Reflexive thematic analysis was used to identify the common factors that may have led to their PPH. The analysis revealed that most participants had challenges associated with their health and its optimal self-management. Self-referral to hospital with the belief that this was the only treatment option available was also common. Most participants had limited social networks to call on in times of need or ill health. Finally, difficulty in accessing primary healthcare, especially urgently or after-hours, was described as a frequent cause of PPH. These qualitative accounts revealed that patients describe nonclinical risk factors as contributing to their recent PPH and reinforces that the views of patients should be included when designing interventions to reduce PPHs.

Note: After Hours, Shows and Showers

This note presents a first glance at two newly discovered texts by Brian O'Nolan. 

Efficiency benchmarks in the surgical management of primary rhegmatogenous retinal detachment: a monocentric register cohort study of operating room time metrics and influential factors

ObjectivesTo investigate the effect of clinical, methodological and logistic factors on operating room (OR) efficiency in the surgical management of primary rhegmatogenous retinal detachment (RRD).DesignMonocentric retrospective register cohort study.SettingSingle tertiary centre in the western region of Austria.ParticipantsWe audited patients diagnosed with primary RRD who were treated between January 2014 and August 2019. In total, 783 eyes of 776 consecutive patients were included in this study. Various risk factors affecting OR time efficiency and anatomical success after pars plana vitrectomy (PPV) procedures and scleral buckle (SB) surgery were analysed.Primary and secondary outcome measuresOR efficiency was the primary outcome measure. Secondary outcome measures were the primary success rate after PPV procedures and SB surgery.ResultsPPV was performed in 641 (81.9%) eyes and SB surgery in 142 (18.1%) eyes. Mean surgical times in PPV and SB under retrobulbar anaesthesia (RA) were 74.0 (±32.6) min and 62.1 (±24.6) min (p<0.001), respectively, while under general anaesthesia (GA), these values were 112.0 (±52.0) min and 76.0 (±22.5) min (p<0.001), respectively. A regression analysis revealed the following main risk factors for prolonged OR time for the surgical management of RRD with PPV (all p<0.001): presence of a giant tear (β=24.01; 32%), proliferative vitreoretinopathy (PVR)-C (β=16.43; 22%), surgery postponed for 72 hours after diagnosis (β=21.40; 29%), GA (β=23.64; 32%) or surgery performed by a trainee (β=17.35; 23%). PVR (p=0.022) in PPV cases, after-hours settings (p=0.006) and surgeon experience (p=0.030) in SB cases were independent risk factors for reduced success rates.ConclusionsOR coordinators should consider various independent clinical (giant tear, PVR-C, advanced detachment), methodological (PPV vs SB) and logistic (GA vs RA, after-hours setting and surgeon experience) factors to improve the success rate and surgical management planning of RRD accurately while optimising OR resources and staff efficiency.

Examining area-level variation in service organisation and delivery across the breadth of primary healthcare. Usefulness of measures constructed from routine data

Background Australia has a universal healthcare system, yet organisation and delivery of primary healthcare (PHC) services varies across local areas. Understanding the nature and extent of this variation is essential to improve quality of care and health equity, but this has been hampered by a lack of suitable measures across the breadth of effective PHC systems. Using a suite of measures constructed at the area-level, this study explored their application in assessing area-level variation in PHC organisation and delivery. Methods Routinely collected data from New South Wales, Australia were used to construct 13 small area-level measures of PHC service organisation and delivery that best approximated access (availability, affordability, accommodation) comprehensiveness and coordination. Regression analyses and pairwise Pearson’s correlations were used to examine variation by area, and by remoteness and area disadvantage. Results PHC service delivery varied geographically at the small-area level–within cities and more remote locations. Areas in major cities were more accessible (all measures), while in remote areas, services were more comprehensive and coordinated. In disadvantaged areas of major cities, there were fewer GPs (most disadvantaged quintile 0.9[SD 0.1] vs least 1.0[SD 0.2]), services were more affordable (97.4%[1.6] bulk-billed vs 75.7[11.3]), a greater proportion were after-hours (10.3%[3.0] vs 6.2[2.9]) and for chronic disease care (28%[3.4] vs 17.6[8.0]) but fewer for preventive care (50.7%[3.8] had cervical screening vs 62.5[4.9]). Patterns were similar in regional locations, other than disadvantaged areas had less after-hours care (1.3%[0.7] vs 6.1%[3.9]). Measures were positively correlated, except GP supply and affordability in major cities (-0.41, p < .01). Implications Application of constructed measures revealed inequity in PHC service delivery amenable to policy intervention. Initiatives should consider the maldistribution of GPs not only by remoteness but also by area disadvantage. Avenues for improvement in disadvantaged areas include preventative care across all regions and after-hours care in regional locations.

Pre- and post-home visit behaviors after using after-hours house call (AHHC) medical services: a questionnaire-based survey in Tokyo, Japan

Background After-hours house call (AHHC) medical services have been implemented in Japan to reduce ambulance use, as well as overcrowding at the emergency department (ED). Examining the pre-and post-home visit behaviors of those using AHHC medical services will provide insights into the usefulness of these services and help develop strategies to reduce ED visits and ambulance use further. Methods This questionnaire-based study used data from anonymized medical records and internet-based questionnaires completed by patients who used AHHC medical services in Tokyo, Japan, between January 1 and December 31, 2019. The questionnaire comprised two questions: (1) What action would the patient have taken in the absence of AHHC services and (2) what action was taken within 3 days following the use of the AHHC services. In addition, following home consultations, AHHC doctors classified the patient’s illness severity as mild (treatable with over-the-counter medications), moderate (requires hospital or clinic visit), or severe (requires ambulance transportation). Results Of the 15,787 patients who used AHHC medical services during the study period, 2128 completed the questionnaire (13.5% response rate). Individuals aged ≤15 years and 16–64 years were the most common users of AHHC services (≤15 years, 71.4%; 16–64 years, 26.8%). Before using the AHHC service, 46.4% of the total respondents reported that they would have visited an ED had AHHC services not been available (≤15 years, 47.8%; 16–64 years, 42.8%; ≥65 years, 43.6%). The proportion of patients originally planning to call an ambulance was higher among those in the older age groups (≤15 years, 1.1%; 16–64 years, 6.0%; ≥65 years, 20.5%). After using the AHHC services, most patients (68.1%) did not visit a hospital within 3 days; however, the proportion of patients who visited an ED and called an ambulance within 3 days increased with the severity of illness. Conclusions Increasing AHHC medical services awareness among older adults and patients assessed as having severe illnesses regularly availing of AHHC services may help reduce ED visits and ambulance use.

“Virtual work-after-work”: the impact of telemedicine on physicians’ after-hours EHR work during the COVID-19 pandemic (Preprint)

BACKGROUND Telemedicine as a mode of healthcare work has grown dramatically during the COVID-19 pandemic; the impact of this transition on clinicians’ after-hours EHR-based clinical and administrative work is unclear. OBJECTIVE This study assesses the impact of the transition to telemedicine work during the COVID-19 pandemic on physicians’ EHR-based after-hours workload (“work-after-work”) at a large academic medical center in New York City. METHODS We conducted an EHR-based retrospective cohort study of ambulatory care physicians providing telemedicine services during the pre-pandemic, acute pandemic, and post-acute pandemic periods, relating EHR-based work after work to telemedicine intensity (percentage of care provided via telemedicine), and clinical load (patient load per provider). RESULTS 2,129 physicians were included in this study. During the acute pandemic, the volume of care provided via telemedicine significantly increased across all physicians, while patient volume decreased. When normalizing for clinical load (average appointments per day by average clinical days per week), telemedicine intensity was positively associated with work-after-work across time periods. This association was strongest in the post-acute period. CONCLUSIONS Taking physicians’ clinical load into account, physicians who devoted a higher proportion of their clinical time to telemedicine throughout the various stages of the pandemic engaged in higher levels of EHR-based after-hours than those who used telemedicine less intensively. This suggests that telemedicine may not be inherently more efficient than in-person-based care, and may not reduce the after-hours work burden of physicians. CLINICALTRIAL N/a