Evidence check
A rapid review outlining the available evidence on a discrete topic or question. Evidence includes grey and peer review literature. View all Evidence Checks by date of publication.
Purchasing for value
Added: 18 Jun 2024
What purchasing or payment models for medical inpatient services have been used to increase value, improve efficiency or reduce length of stay?
What is the evidence for length of stay and cost-effectiveness of the hospital in the home (HITH) models as compared to inpatient care for acute conditions?
What is the evidence for length of stay and cost-effectiveness of the hospital in the home (HITH) models as compared to inpatient care for acute conditions?
- In Australia, activity-based funding based on the diagnostic related groups (DRGs) classification system is the dominant purchasing model for hospital-admitted patient services. This model has advantages of being transparent, increasing activity levels and reducing the length of stay compared to fee-for-service models. It also has disadvantages, including insufficient cost control, lack of consideration for value and care integration, the likelihood of unnecessary patient admissions, higher readmission rates or upcoding treatment decisions for larger payments.
- Given the disadvantages and side effects of DRG-based payment models, many high-income Organisation for Economic Co-operation and Development (OECD) countries are reducing the overall share of inpatient payments based on DRGs and moving towards integrating value-based payment models.
- Value-based payment models are a key driver of health system transformation and can contribute to reducing low-value services, increasing efficiency, improving quality of care and promoting better care coordination.
Medical Assessment Unit
Added: 18 Jun 2024
Does admission or assessment through a medical assessment unit (MAU) or acute medical unit (AMU) increase hospital discharges, and improve patient outcomes and hospital resource usage?
- A medical assessment unit (MAU) or acute medical unit (AMU) can act as the first point of entry for patients referred from the community for acute medical emergencies. It provides rapid assessment, investigation, stabilisation, and treatment for patients. The design and configuration of MAU can vary depending on jurisdictions or hospitals, but usually, the ED is bypassed by providing direct access to an acute assessment.
- Implementation of acute medical units were associated with reduced mortality, increased admission capacity and reduced hospital length of stay.
- Same day emergency care (SDEC) is a model that is currently being implemented in NHS England. In this model, patients are assessed for suitability for discharge without an overnight stay. Further assessment, treatment and follow-up can be delivered via an alternative pathway such as outpatient services, virtual wards or hospital at home. SDEC is often embedded within or adjacent to the AMU.
Hospital in the home
Added: 18 Jun 2024
What is the evidence for length of stay and cost-effectiveness of the hospital in the home (HITH) models as compared to inpatient care for acute conditions?
- The definition and measurement of the length of stay in models involving HITH varies across studies, with some reporting on the length of stay while occupying a hospital bed while others reporting on the length of stay or treatment for both the hospital and HITH stays. Overall, the evidence suggests that HITH reduces the number of hospital bed days. However, the evidence on the total number of days patients receive care/treatment is mixed and some studies reported it increased with HITH compared to inpatient care only.
- The admission avoidance (step-up) model was associated with lower cost, lower mortality rates and comparable or lower readmissions to inpatient care.
- The early supported discharge (step-down) model was associated with comparable mortality, readmission and a shorter hospital length of stay to inpatient care. The findings on costs were mixed and likely due to differences in patient characteristics, interventions, cost components and cost measures, with some reporting reduced costs while others reporting increased overall costs.
Time-based targets for ED stays
Added: 18 Jun 2024
What are the time-based targets for length of stay in emergency departments (ED) across major health systems and what is the impact of these targets on outcomes?
How do they compare to the new targets in NSW?
How do they compare to the new targets in NSW?
- In Australia and across major health systems, the time-based access targets for ED stays varied across jurisdictions.
- Literature on assessing the impact of time-based ED targets on patient, clinician and system outcomes comprises mainly observational studies with varying degrees of quality. Compared to pre-introduction, there is evidence to demonstrate the benefits of introducing targets in reducing mortality, ED crowding, time to assessment and admission. There is also evidence of some unintended consequences such as performance data manipulation or increased pressure on staff.
- Qualitative evidence suggested that ED clinicians perceived the time-based targets as having both positive and negative impacts on quality of care.
Demand management in radiology
Added: 18 Jun 2024
What are the demand management strategies for radiology services?
- Single or multi-component interventions that have shown to reduce low-value imaging by more than 30% include clinical decision support systems, education, feedback, specialist involvement in ordering examinations, guideline implementation, and health information exchange. Most interventions target the referring physicians.
- Multi-component interventions are more likely to be effective than single-component interventions. Targeting high-referrers of low-value imaging is a promising strategy.
- There is emerging evidence that machine learning and deep-learning based methods for clinical decision support and auto-vetting the appropriateness of imaging referrals can help to curb the low-value and inappropriate use of imaging examinations.
Digital mental health interventions for young people
Added: 27 Mar 2024
For young people aged 12-25 years with severe and complex mental illness, which supported online mental health treatments (delivered in partnership with, or alongside specialist community mental health care): have been shown to be most effective in delivering positive mental health outcomes? have been shown to be most cost-effective?
For young people aged 12-25 years with severe and complex mental illness, which online social therapies (delivered in partnership with, or alongside specialist community mental health care) have been shown to be most effective (or promising) in delivering positive social and mental health?
For young people aged 12-25 years with severe and complex mental illness, which online social therapies (delivered in partnership with, or alongside specialist community mental health care) have been shown to be most effective (or promising) in delivering positive social and mental health?
- Digital mental health interventions (DMHIs) for young people are an emerging area. Studies generally comprise small sample sizes, include participants with a mix of mental health severity and use self-reported symptoms or clinician-rated and diagnosed conditions.
- For less severe mental health conditions or self-reported elevated symptoms, there is evidence to support the effectiveness of DMHIs in improving symptoms. Especially internet-delivered cognitive behavioural therapies (iCBT) when delivered in-person or via virtual coaching including follow-up.
- For online social therapies, the findings suggest effectiveness in improving vocational or educational attainment, reducing emergency visits and overall cost-savings when used alongside treatment as usual. However, the intervention did not demonstrate a significant benefit in improving social functioning.
Post-tonsillectomy bleeding and pain
Added: 5 Feb 2024
Are there any patterns or risk stratification for post-tonsillectomy bleeding and pain?
Do the following factors influence the likelihood of post-tonsillectomy bleeding and pain?
What are the main reasons for patients presenting to the emergency department (ED) following tonsillectomy surgery?
When (how many days after) do patients usually present to an ED after the surgery?
How long do patients need to stay close to where they had the tonsillectomy surgery, especially in rural or regional areas?
Do the following factors influence the likelihood of post-tonsillectomy bleeding and pain?
- Surgery technique.
- Patient and clinical characteristics.
What are the main reasons for patients presenting to the emergency department (ED) following tonsillectomy surgery?
When (how many days after) do patients usually present to an ED after the surgery?
How long do patients need to stay close to where they had the tonsillectomy surgery, especially in rural or regional areas?
- The method and techniques of tonsillectomy can be associated with different risk profiles for post-operative haemorrhage and pain in both paediatrics and adults. Overall, the intracapsular coblation method appears to be associated with lower risks of bleeding and pain compared to other methods. Several patient and clinical characteristics, such as male gender, older age (15 years or over), multiple indications for surgery, comorbidity and coagulopathy, and the severity of illness at admission, are associated with an increased risk of post-tonsillectomy bleeding.
- The main reasons for presenting to an ED following tonsillectomy surgery include bleeding, dehydration, infection, nausea and pain in paediatrics. For adults, the most common reasons include pain and bleeding. The median days to presentation post-operation ranged from 5-7 for paediatrics and a similar range for adults.
- The evidence evaluating the safe geographical proximity or travel distance for patients to stay close to where they had the operation is scant.
Post-tonsillectomy bleeding in children
Added: 3 Nov 2023
What are the risks of bleeding after tonsillectomy surgery in children? What are the management options?
- In Australia, between 2000 and 2020, the overall rate of post-tonsillectomy haemorrhage for all ages remained relatively constant at around 1.6%.1 The rate for the paediatric age group was around 1% for the study period.
- In patients who present to the emergency department (ED) with secondary post-tonsillectomy bleed, an Australian study found that the average post-operative day of presentation was 7. The risk of rebleeding was 2.9% and the median time to rebleed was 4.4 hours.
Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health. Evidence checks are archived a year after the date of publication.