How can we improve access to care?

Every year, RCH outpatient (OP) clinics see in excess of 270,000 children and the number of referrals to RCH OP clinics has increased by 94% over the last six years.

Some clinics have wait lists more than 12 months yet many families do not turn up to their booked appointments. Similarly, there have been increasing numbers of children presenting to emergency departments (EDs) across Victoria. Over the last decade, paediatric referrals from general practitioners (GPs) to the ED have increased by 60% in Australia. Children aged zero to four years now make up the largest age category presenting in Victoria, far exceeding adults.

There is anecdotal evidence that many of these children could be safely managed outside the hospital setting for their diagnosis and/or ongoing management. Directing children away from the ED or OP clinics towards community-based care could improve access to specialist care for children with more complex conditions. However, concern exists regarding the skill level of community providers to manage health conditions.

The HSRU is conducting a number of studies examining the interface between community care and hospital OP clinics and ED. 

Current projects

Strengthening Care for Children (NHMRC Partnership Grant 2020-2023)

Building on the pilot study HSRU conducted in 2017-2019 (see Completed Projects below), the Strengthening Care for Children (SC4C) project is a four-year stepped-wedge randomised control trial funded through an NHMRC Partnership. The SC4C trial is being conducted across Victoria and New South Wales in collaboration with the Murdoch Children’s Research Institute, University of Melbourne, University of New South Wales, Macquarie University, Sydney Children’s Hospital Network, North Western Melbourne Primary Health Network, Central & Eastern Sydney Primary Health Network, Agency for Clinical innovation (NSW Health) and Sydney Partnership for Health, Education, Research and Enterprise (SHPERE).

The aims of the SC4C trial are to reduce GP referrals to hospital Outpatient Clinics and Emergency Departments, increase GP confidence in paediatric healthcare and adherence to clinical guidelines, and decrease family preference for a specialist paediatric referral.

Trends in Paediatric Presentations to Victorian Emergency Departments Pre-Covid-19

Using routinely collected data from Victorian public hospital Emergency Departments, this project aims to examine pre-Covid-19 trends and characteristics of paediatric ED attendances in Victoria. We will examine patterns of low urgency presentations, high frequency attendees to ED, and chronic illness related presentations, including diabetes-related attendances to ED to understand the characteristics of these presentations and associated costs.

This project will establish trends in paediatric ED attendances pre-Covid-19, and will allow for future research to examine the impact of Covid-19 on paediatric health service use.

A Model to Predict and Prevent ‘Failure to Attend’ Patients in the General Medicine Outpatient Clinic at RCH

Patients who fail to attend (FTA) their appointment account for 23% of all outpatient appointments in the General Medicine department of The Royal Children’s Hospital (RCH). This equates to over 2500 wasted appointments every year. With an increasing paediatric population and waitlists of up to two years for these outpatient clinics, FTA appointments represent a large burden on already limited resources.

This project aims to understand patient and system characteristics associated with FTA, as well as the associated costs with FTA appointments. From there, we will develop and test an appropriate intervention aimed at reducing FTA appointments.

Managing childhood enuresis in the community

We aim to co-develop and pilot a new community based enuresis program in collaboration with the General Medicine enuresis outpatient clinic at The Royal Children’s Hospital (RCH), General Practitioners (GPs) and the North Western Melbourne Primary Health Network (NWMPHN). We will evaluate whether the new program can reduce the number of children who currently wait up to 18 months to be seen at the RCH for primary nocturnal enuresis, when these children could be safely cared for in the community. The community-based, nurse-led model will treat and support children with primary nocturnal enuresis and identify children that require specialist treatment.  

Completed projects

Strengthening Care for Children (Pilot Study)

The Strengthening Care for Children (SC4C) study piloted an integrated general practitioner (GP)-paediatrician model of care in 6 GP practices in north-west Melbourne. Over 12 months, 49 GPs and 896 families participated in the intervention that included weekly to fortnightly paediatrician-GP co-consultation sessions at the general practice, monthly case discussions and telephone or email clinical support for GPs. The model of care was found to be feasible and acceptable, lead to a lower proportion of referrals to specialist paediatric care, and reduced unnecessary prescribing of acid suppression therapy and antibiotics. GPs reported increased confidence in paediatric care and, similarly, families reported increased confidence in their GP.

The SC4C Pilot led to a successful application for an NHMRC Partnership Grant (see Current Projects above).

Reference

• Hiscock H, O’Loughlin R, Pelly R, Laird C, Holman J, Dalziel K, Lei S, Boyle D, Freed G. Strengthening care for children: Pilot of an integrated GP-paediatrician model of primary care in Victoria. Australian Health Review 12 February 2020

Why do outpatient clinic appointments go unattended?

We know that up to 20% of specialist outpatient clinic appointments are unattended, with families missing their appointment for any number of reasons. This is despite very long wait lists for appointments. We are interviewing families who had an appointment, but did not attend, with the aim to find out why the appointment was missed so that we can increase the efficiency of the outpatient clinics into the future. Through this project, we will determine what we can do to help families get to their appointment or to cancel it in time so that another child can be seen.

Reference

• Christie-Johnston CA, O’Loughlin R, Hiscock H. “Getting to Clinic Study” – a mixed methods study of families who fail to attend hospital outpatient clinics. Journal of Paediatrics and Child Health 2019 Nov 12. doi: 10.1111/jpc.14672

RCH Outpatient Clinic Efficiency

Over a 12 month period spanning May 2015 to April 2016, we conducted an audit of the efficiency in use of five outpatient clinics at RCH. We looked at differences in the availability of new versus review appointments, and any differences in the proportion of the available appointments that were booked in, and attended, by clinicians and families. We found wide variation in clinic attendance but no seasonable variation. ‘Review’ appointments were less well attended by families than ‘new’ appointments. 

Related projects

Prof Hiscock is conducting related projects through the Health Services research group at MCRI. You can read more about these projects here.

Collaborations

National: RCH; MCRI; University of Melbourne; Sunshine Hospital; NWMPHN; Werribee Mercy Hospital; Department of General Practice, University of Melbourne; Curve Tomorrow.

International: USA - University of Michigan, Child Health Evaluation and Research Center (Prof Gary Freed) and Stanford University (Dr Lee Sanders); Canada - Toronto Sick Kids (A/Prof Eyal Cohen) and   (Prof Astrid Gutmann); Ireland – Trinity College, Dublin (A/Prof Maria Brenner); UK – King’s College London (Prof Ingrid Wolfe) and University College London (Dr Dougal Hargreaves); Sweden – Karolinska Institute (Prof Anders Hjern).

Datasets

Victorian Admitted Episodes Dataset (VAED); The Royal Children’s Hospital (RCH; Epic); Generic Health Network Information Technology for the Enterprise (GRHANITE); Australian Paediatric Research Network (APRN).

Funding sources

RCH Foundation; Better Care Victoria (DHHS), MCRI.