The proposed project will undertake Phase Three of this multi-phased project, leveraging from the first two project phases which will have defined both current practice, and practice evidence benchmarks.
Phase Three will (i) quantify the ‘evidence-practice gap'; (ii) conduct a gap driver analysis to identify barriers or facilitators of the variability in clinical practice, and (iii) identify financial costs associated with deviation of care from agreed best practice standards.
Project Importance: Around 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year. Despite this relatively low incidence, the costs associated with TSCI are extremely high; the lifetime cost for paraplegia is estimated at $5 million and for tetraplegia, $9.5 million. Acute phase hospital and long term care costs combined consume over half of the total costs claimed for patients with TSCI; yet there is no report to date, addressing the acute care costs or the influence of health service efficiency and process on these costs. The early phase of care holds high risks for secondary neurological injury with time-dependent mechanisms increasing cord damage, and complications such as sacral and occipital pressure ulcers or urinary tract infections significantly impacting on the long term recovery and outcomes of TSCI. Such complications also cost the patient, quality of life and effective and timely recovery. Inconsistencies in policy, variations in practice and lack of care coordination across care providers have been shown to introduce delays in patient care. The economic burden of acute TSCI care in Australia is not clearly understood, nor the degree to which variation in practice and institutional performance impacts on cost and is amenable to change.
Identifying cost drivers: The Independent Hospital Pricing Authority has recently reported increases in the costs of acute TSCI; with a 30% increase in the average cost per patient episode across Australian hospitals in 2011-12 for one of the four spinal cost group codes (DRG B60A). To date these data are not well explained. There may be some legitimate disparities in health care service costs; however, where predictors of higher costs can be identified, modifiable variations are likely. Prolonged hospitalisation has been predominantly attributed to system related issues, as opposed to severity of illness in a large group of trauma patients; including difficulties in transfer to a rehabilitation facility or in-hospital operational delays such as delay to timing of surgery. In an environment of increasing healthcare costs and competition for finite resources, economic data relating to the cost of injury and illness is integral to guiding health services policy.
Understanding the Evidence-Practice Gap: In order to achieve improvement and innovation in public health and health service delivery it is critical to understand the "know-do" gap. The ‘knowing' (what to do for ‘best practice') is the evidence to optimise healthcare and injury outcomes. The ‘doing' is the practice (what is actually being done), demonstrated by observational data, and the ‘gap' between the two defines the opportunity for improvement representing clinical variation and the underlying drivers (the health professional, environmental and institutional barriers and facilitators to best practice), that are impeding consistency and quality of health care and outcomes and likely impacting on costs.
Phase One: A current prospective study (NHMRC ‘Access to Care' Partnership Project) is documenting the earliest part of the clinical journey of a person with TSCI from scene of injury to definitive diagnosis and specialised treatment in a designated specialist spinal cord injury unit. This study will provide high quality, prospective clinical, protocol, and timing data quantifying the nature of current practice, and the system or clinical variations between local health districts across NSW. This study is in the last months of recruitment, with currently 306 patients enrolled. Data include date, time, injury epidemiology; ambulance response, assessments and management; all episodes of hospital care including assessments, vital signs, diagnoses and treatment, interhospital transfers, surgical interventions and their timing, lengths of stay and complications. Telephone follow-up interviews have been conducted on patients where possible, at 6, 12 and 24 months. The proposed study will obtain identified cost data for all such acute care episodes, linked back to the Access to Care database.
Phase Two: A Delphi process is being used to provide consensus, expert opinion on what constitutes best practice in the acute phase of care for patients with TSCI. This second current study (Sydney Medical School Early Career Research grant 2015) is defining ‘agreed evidence based standards for practice'; one of the first and most crucial steps before the translation of knowledge into policy and practice. The components of acute TSCI care involved in the Delphi process include pre-hospital care, spinal immobilisation, imaging, haemodynamic management, time to surgery and referral pathways and processes. Key drivers of barriers to or facilitators of adherence to the best practice pathways will be described and explored by surveys of key stakeholders within the trauma system. Barriers and facilitators to best practice are anticipated to include the health professional, environmental and institutional practice and policy. Hospital codes (DRGs) will be explored to identify clinical complications such as urinary tract infections or deep vein thrombosis, and inpatient length of stay or readmissions post-acute phase will all generate data points that indicate drivers to gaps in care. The mapping of patient pathways to current state guidelines or protocols will identify lack of adherence to these, and may highlight patient consequences or groups at high risk.
The opportunity ID for this research opportunity is 50