Improving care standards and costs for spinal trauma patients
Summary
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.
Supervisor
Research location
North Shore - Kolling Institute of Medical Research
Synopsis
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.
Additional information
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.