We admit over 6000 mostly elderly multi-morbid patients annually. We need to ensure patients reach wards promptly after ED arrival, optimise treatment, minimise unnecessary hospital stay, transition patients to the community efficiently and prevent unnecessary readmission. We are also aiming to improve the way our system prioritises outcomes related to symptom relief, independent function and quality of life in this group. We believe that applying research methods to evaluating our service performance are vital to addressing this aim.
Where clear evidence for particular treatments exists we implement this however trials are done on highly selected patient populations that are not representative of those we actually treated. Real patients and staff don’t behave like those in trials. Therapeutic benefits shown in randomised controlled trials are commonly reduced in real patients. Our research addresses gaps in both treatment and treatment delivery. This is real world translation, implementation, health service delivery and health economic research.
We have completed research on length of stay and clinical costs in diabetes and lower limb cellulitis with high-level publications (including 1st author publications by our registrars in JAMA and the Journal of Antimicrobial therapy) and RACP registrar prizes. We secured a $300K HCF research foundation grant to evaluate a new model of care for managing community acquired pneumonia (the “Improve-GAP” trial).
Another major project (RAPT) focused on identifying and following up patients at high readmission risk. We also monitored a multipronged approach to markedly shortening time from arrival in ED to the wards.
- Preventing Diabetes in Pregnancy from Progressing to Type 2 Diabetes: Macro-Level System Change in South Australia and Victoria (MAGDA)
Researcher: Prof Edward Janus
Collaborators: JA Dunbar, JD Best, R Carter, J Oats, M Ackland and P Ebeling
Study 1: Using GHRANITE encrypted linkage technology an analysis of multiple Gestational Diabetes Mellitus (GDM) related data sets from hospitals, government and pathology laboratories is continuing. In this way a large amount of information can be gathered for an individual while protecting their identity. The individuals’ condition can be tracked over time to test if the appropriate interventions are happening.
Research on a gestational diabetes register aims to ensure long term follow up and an intervention (MAGDA) to decrease progression of GDM mothers to type 2 diabetes.
Study 2: Recruitment of all 578 subjects for the lifestyle intervention vs usual care and the intervention was completed mid 2015 with a large contribution from WH.
The intervention trial results were published in 2016. 10% of pregnancies at Western Health are complicated by gestational diabetes. As well as optimal treatment during pregnancy follow up is critical to prevent later development of type 2 diabetes and its complications in these mothers. This process and effective interventions to prevent later diabetes have been lacking and this very large project addressed these issues.
- EPI-FIND – Epigenetic Factors in Diabetes
Researcher: Prof Edward Janus
Collaborators: L Ackland (Deakin University), J Dunbar (Deakin University) and JD Best (previously University of Melbourne)
A MAGDA spin-off project identified epigenetic (environmental) effects on gene expression in the development of diabetes during pregnancy. Subjects are drawn from Western Health Gestational diabetes and non-gestational diabetes clinics. The pilot study showed differences between a number of groups.
This was published in 2016. It appears that environmental factors interact with genes to produce adverse effects on both mothers and their babies e.g. malnutrition during pregnancy has long term health implications for the babies who may develop heart disease and diabetes in adult life.
Understanding how this happens will inform strategies to prevent intergenerational transmission of these common diseases.
- False Economies in Home-Based Antibiotic Treatment: A Health-Economic Case Study of Management of Lower-Limb Cellulitis at a Large Metropolitan Health Service
Researchers: K Kameshwar, A Karahalios, Prof Edward Janus and Harin Karunajeewa
This is our seminal health systems/ health economic research project in which we have proved the principle that we can interrogate the administrative data sources at Western Health to produce high quality published research that has direct relevance to service delivery planning at WH. We hope it will be a platform that will help us leverage dedicated funding and position WH as a leader in health services/ health economic research.
Cellulitis is an extremely common (330 inpatient admissions per year) and costly condition to manage ($1.7 million) at WH. Improving efficiency of management will ensure resources are freed up for where they can be used more effectively.
The study results were published in 2015 and we responded to relevant letters to the editor in 2016.
- IMPROVE-GAP: IMPROVing Evidence-Based Treatment Gaps and Outcomes in Community Acquired Pneumonia: Standardizing Evidence-Based Interventions to Shorten Length of Stay, Reduce Readmissions, Reduce Hospital Costs and Improve Patient-Reported Outcomes
Researchers: Prof Edward Janus, A/Prof Harin Karunajeewa, Elizabeth Skinner, ML Ong, M Shackell, M Boyd, A Karahalios, AM Kelly and R Harrison
Collaborator: Prof Terry Haines (Monash University)
This is a controlled evaluation, utilizing a novel “stepped-wedge” clinical research design, to evaluate a new model of care for managing community acquired pneumonia (the “Improve-GAP” trial). Improve-Gap aims to address the gap between evidence (including routine use of steroids, early mobilization antibiotic stopping rules) and practice.
This study started in October in 2016 and aims to recruit 800-1000 patients. As of December 2016, 300 patients have already been recruited into the study.
Community acquired pneumonia is the most common and costly condition we treat at WH. Improvements in efficiency will pay a large dividend for patient outcomes and resource utilization. We hope that this study will build a platform for further studies of acute respiratory infections, enable further internal and external collaboration, further successful funding applications and see WH positioned as a scientific leader in this field.
Other sub-studies have commenced including patient reported outcome measures (PROMS).
- International Statistical Classification of Diseases and Related Health Problems Coding Underestimates the Incidence and Prevalence of Acute Kidney Injury and Chronic Kidney Disease in General Medical Patients
Researchers: Dr Soe Ko, A/Prof Vicki Levidiotis, A/Prof Craig Nelson, Prof Edward Janus and Dr Kushma Nand
Collaborator: Sudharsan Venkatesan
We set out to compare diagnosis of Acute Kidney Injury (AKI) and/or Chronic Kidney Disease (CKD) using International Statistical Classification of Diseases and Related Health Problems (ICD 10) coding with Kidney Disease: Improving Global Outcomes (KDIGO) criteria, to identify the proportion of patients with AKI and/or CKD as per KDIGO criteria and to evaluate their impact on clinical outcomes.
When the gold standard KDIGO criteria are used close to 70% of admissions to General Internal Medicine have kidney injury which may be acute, chronic or both. Review of records shows that a substantial number are missed and not coded with significant clinical implications for the patient and financial implications for the health service.
Bill and Melinda Gates Grant
H Karunajeewa (PI), I Mueller and JK Baird. Finding the Best Treatment for Vivax Malaria in the Solomon Islands. Bill and Melinda Gates Foundation, $1,300,000 (2016–2018)
HCF Project Grant
E Janus, H Karunajeewa, E Skinner, ML Ong, A Karahalios, R Harrison and T Haines. Hospitalisation for Pneumonia in the Elderly: Standardising Evidence-Based Interventions to Shorten Length of Stay, Reduce Readmissions, Reduce Hospital Costs and Improve Patient-Reported Outcomes. HCF, $300,000 (2016–2017)
- Kameshwar K, Karahalios A, Janus E and Karunajeewa H. False economies in home-based parenteral antibiotic treatment: A health-economic case study of management of lower limb cellulitis in Australia – authors response. Journal of Antimicrobial Chemotherapy. 2016 71 (8): 2363 doi:10.1093/jac/dkw140
- Michalczyk AA, Dunbar JA, Janus ED, Best JD, Ebeling PR, Ackland MJ, Asproloupos D and Ackland ML. Epigenetic markers to predict conversion from gestational diabetes to type 2 diabetes. Journal of Clinical Endocrinology and Metabolism 2016 Jun; 101(6):2396-404. doi:10.1210/jc.2015-4206.
- O’Reilly SL, Dunbar JA, Versace V, Janus E, Best JD, Carter R, et al. MAGDA Research Group. Mothers after Gestational Diabetes in Australia (MAGDA): A Randomised, Controlled Trial of a Postnatal Diabetes Prevention Program in PLOS Medicine Special issue on diabetes Prevention Guest editors Prof Nick Wareham and Prof William Hermann.. PLoS Med 13(7): e1002092.doi:10.1371/journal.pmed.1002092 First published on line July 22, 2016.
- Lee CH, Shih AZL, Woo YC, Fong CHY, Leung OY, Janus E, et al. Optimal Cut-Offs of Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) to Identify Dysglycaemia and Type 2 Diabetes: A 15 Year Prospective Study in Chinese. PLoS ONE 11(9): e0163424. doi10.1371/journal.pone.0163424.
- Dimitri M, Janus E, Karunajeewa H. Intensive vs Standard Blood Pressure Control for Older Adults. JAMA. 2016; 316(18):1921-1922. doi: 10.1001/jama.2016.14921.
- Manning L, Cutts J, Stanisic DI, Laman M, Carmagnac A, Allen S, O’Donnell A, Karunajeewa H, Rosanas-Urgell A, Siba P, Davis TM, Michon P, Schofield L, Rockett K, Kwiatkowski D, Mueller I. A Toll-like receptor-1 variant and its characteristic cellular phenotype is associated with severe malaria in Papua New Guinean children. Genes Immun. 2016 Jan-Feb;17(1):52-9.
- Uyoga S, Ndila CM, Macharia AW, Nyutu G, Shah S, Peshu N, Clarke GM, Kwiatkowski DP, Rockett KA, Williams TN; MalariaGEN Consortium. Glucose-6-phosphate dehydrogenase deficiency and the risk of malaria and other diseases in children in Kenya: a case-control and a cohort study. Lancet Haematol. 2016 Oct;2(10):e437-44.
- Karunajeewa HA, Mueller I. How important is gametocyte clearance after malaria therapy? BMC Med. 2016 Jun 18;14:93.
- Busby GB, Band G, Si Le Q, Jallow M, Bougama E, Mangano VD, Amenga-Etego LN, Enimil A, Apinjoh T, Ndila CM, Manjurano A, Nyirongo V, Doumba O, Rockett KA, Kwiatkowski DP, Spencer CC; Malaria Genomic Epidemiology Network. Admixture into and within sub-Saharan Africa. Elife. 2016 Jun 21;5. pii: e15266