OBJECTIVES:Australia is among the few large jurisdictions to experience more than one pandemic wave preceded by no incident COVID-19 cases. This enables research to estimate the immediacy, extent and duration of impact of those waves on initial admission and readmission rates for patients with congestive heart failure (CHF), as an example of high users of hospital services. METHODS:We used single and controlled interrupted time series designs, segmented regression analyses, and linked administrative data from 2016 to 2021. RESULTS:Patients with CHF experienced immediate and sizable reductions in weekly acute initial admissions of 26% and 16% for up to 3-5 months after the first and Delta waves in 2020 and 2021, respectively. Unplanned readmissions within 30 days declined by 2.30 and 3.59 percentage points (10-16% rate reduction) and remained lower than expected for more than 4-5 months after both waves. These reductions occurred after years of stability in these measures. Reductions commenced before the World Health Organization declaration in 2020 and coincided with stay-at-home orders in 2021. There was no significant change in the average length of stay. CONCLUSIONS:Pandemic waves and restrictions in New South Wales resulted in rapid, sizable, and sustained reductions in initial admission and readmission rates among patients with CHF, suggesting that clinician, patient and/or family decisions reduced potentially preventable admissions, as these decisions occurred before or at the time of public health declarations. Future studies should explore the potential impact of this magnitude of reduction on the health outcomes of patients with CHF.

Background The quality of food service is vital to patients’ experiences in care and recovery in hospitals. This study aimed to identify opportunities for improving hospital food services to enhance overall patient experiences and outcomes. Methods This retrospective cross-sectional study uses the Adult Admitted Patient Survey in 2019. Adult patients discharged from acute or rehabilitation care across 75 public hospitals were surveyed about their in-hospital experiences, including ratings of hospital food services, overall ratings of hospital care, complications acquired, and delayed discharge due to feeling unwell. Population weighting was applied in descriptive and multivariable logistic regression analyses. We used adjusted odds ratios (AORs) and 95% confidence intervals (CIs) to estimate the association between hospital food service and the overall rating of hospital care and two recovery outcomes. Results Eight in ten participants (weighted, 16,919/21,900) consumed food in a hospital [mean age: 60.6 years (SE:0.5; SD: 18.3), 53% female]. Compared to a fair rating, adults who rated “poor/very poor” of hospital food service were 2.7 times more likely to report dissatisfaction with overall care in the hospital [Adjusted Odds Ratio (AOR) (95% CI): 2.73 (1.49, 4.99)], 1.4 times more likely to report complications [AOR:1.43 (1.11, 1.83)] and 1.9 times more likely to report delayed discharge [AOR 1.85 (1.30, 2.62)]. More moderate ratings were associated with attenuation of risk for these outcomes. Furthermore, the magnitude of the effect for these associations was more substantial among patients from non-English-speaking backgrounds (n = 1,759) after controlling for patient characteristics. Food service attributes, including received food as ordered, food delivered within reach, the taste of the meals, and meal interruption, were significant factors for the outcomes assessed. Conclusion These findings underscore the importance of patients’ positive experiences of hospital food service in recovery outcomes and identify several food service indicators that can be used to monitor and improve patient experiences and recovery outcomes in hospitals.

#Policy Points The implementation of large-scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge. Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture. Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty.ContextLarge-scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large-scale transformation in health care systems.MethodsA realist study of the implementation of a value-based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context-mechanism-outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers.FindingsForty-two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large-system transformation that illustrates when, for whom, and in what circumstances large-system transformation worked well or worked poorly.ConclusionsSystem enablers offer nuanced guidance for the implementation of large-scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large-system value-based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care.

Background This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals’ capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers’ ability to cope with unexpected scenarios is key to managing change. Methods We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. Results CMO statements were refined for four initial program theories: Making it Relevant– where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement– where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss– where the effects of staff turnover were mitigated; and Community-Wide Priority– where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. Conclusions A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

IntroductionEvidence on patient experiences with pain in hospitals and its impact on post-discharge outcomes is limited. This study investigated the prevalence of pain in hospitals, patient characteristics associated with pain management adequacy, and the link between pain experiences, care ratings, readmission and emergency department visits after discharge.MethodsWe conducted a retrospective cross-sectional analysis of the 2019 Adult Admitted Patient Survey, focusing on self-reported pain experiences, including presence, severity and management adequacy. The outcomes included self-reported overall care ratings; readmission; and emergency department visits within one month of discharge. Multivariable logistic regression adjusted for population weight was used to estimate adjusted odds ratios.ResultsAmong 75 large public hospitals, 21,900 patients responded (35% response rate), with 51% of patients reporting pain (mean (SD) age 57 (8.8) y; 54.9% female), 38.3% of whom classified their pain as severe. Aboriginal and/or Torres Strait Islander people and patients who spoke a language other than English were less likely to report adequate pain management (aOR (95%CI) 0.74 (0.58-0.96) and 0.82 (0.70-0.96), respectively). Pain also correlated with poor to very poor care ratings (aOR (95%CI) 2.05 (1.42-2.95)). Those patients who experienced pain were twice as likely to be readmitted (aOR (95%CI) 1.92 (1.55-2.37)) or visit the emergency department after discharge (aOR (95%CI) 1.91 (1.58-2.32)). Conversely, adequate pain management was associated with a lower likelihood of readmission (aOR (95%CI) 0.69 (0.51-0.94)) and emergency department visits (aOR (95%CI) 0.62 (0.44-0.87)). Mediation analysis suggests adequate pain management significantly mediated the relationship between pain severity and hospital rating (50.8%), readmission (11.6%) and emergency department visits (5.9%), after adjusting for all available observed confounders.DiscussionThis study highlights the importance of adequate pain management in patients' perception of care and recovery outcomes, especially among culturally and linguistically diverse patients.

Abstract Aims Reducing preventable hospitalization for congestive heart failure (CHF) patients is a challenge for health systems worldwide. CHF patients who also have a recent or ongoing mental disorder may have worse health outcomes compared with CHF patients with no mental disorders. This study examined the impact of mental disorders on 28 day unplanned readmissions of CHF patients. Methods and results This retrospective cohort study used population‐level linked public and private hospitalization and death data of adults aged ≥18 years who had a CHF admission in New South Wales, Australia, between 1 January 2014 and 31 December 2020. Individuals' mental disorder diagnosis and Charlson comorbidity and hospital frailty index scores were derived from admission records. Competing risk and cause‐specific risk analyses were conducted to examine the impact of having a mental disorder diagnosis on all‐cause hospital readmission. Of the 65 861 adults with index CHF admission discharged alive (mean age: 78.6 ± 12.1; 48% female), 19.2% (12 675) had at least one unplanned readmission within 28 days following discharge. Adults with CHF with a mental disorder diagnosis within 12 months had a higher risk of 28 day all‐cause unplanned readmission [hazard ratio (HR): 1.21, 95% confidence interval (CI): 1.15–1.27, P‐value < 0.001], particularly those with anxiety disorder (HR: 1.49, 95% CI: 1.35–1.65, P‐value < 0.001). CHF patients aged ≥85 years (HR: 1.19, 95% CI: 1.11–1.28), having ≥3 other comorbidities (HR: 1.35, 95% CI: 1.25–1.46), and having an intermediate (HR: 1.34, 95% CI: 1.28–1.40) or high (HR: 1.37, 95% CI: 1.27–1.47) frailty score on admission had a higher risk of unplanned readmission. CHF patients with a mental disorder who have ≥3 other comorbidities and an intermediate frailty score had the highest probability of unplanned readmission (29.84%, 95% CI: 24.68–35.73%) after considering other patient‐level factors and competing events. Conclusions CHF patients who had a mental disorder diagnosis in the past 12 months are more likely to be readmitted compared with those without a mental disorder diagnosis. CHF patients with frailty and a mental disorder have the highest probability of readmission. Addressing mental health care services in CHF patient's discharge plan could potentially assist reduce unplanned readmissions.

Background: Frailty risk estimated using hospital administrative data may provide a useful clinical tool to identify older hip fracture patients at-risk of fracture-related readmissions and mortality. This study examined hip fracture hospitalisation temporal trends and explore the role of frailty risk in fracture-related readmission and mortality.Methods: This retrospective cohort study was conducted using linked hospital admission and mortality data in New South Wales, Australia. Patients aged >= 65 years were admitted after a hip fracture between 2014 and 2021 for temporal trends and those admitted and discharged after a hip fracture in 2014-2018 for fracture-related readmission. The Hospital Frailty Risk Score was estimated, and patients were followed for at least 36 months after discharge. A semi-competing risk analysis was used to examine the associations of frailty with fracturerelated readmission and/or mortality.Results: Hip fracture hospitalisation rate was 472 per 100,000 and declined by 2.9 % (95 % confidence intervals (CI): -3.7 to -2.1) annually. Amongst 28,567 patients, 9.8 % were identified with low frailty risk, 39.4 %, intermediate frailty risk, and 50.6 % with high frailty risk. Patients with intermediate or high frailty risk had a higher chance of fracture-related readmission (Hazard ratios (HR): 1.33, 95 %CI: 1.21-1.47, HR: 1.65, 95 %CI: 1.49-1.83), death (HR: 1.50, 95 %CI: 1.38-1.63, HR: 1.80, 95 %CI: 1.65-1.96) and death post fracture-related readmission (HR: 1.32, 95 %CI: 1.12-1.56, HR: 1.56, 95 %CI: 1.32-1.84) than those with low frailty risk.Conclusions: It appears that frailty risk estimated using hospital administrative data can contribute to identify patients who could benefit from targeted interventions to prevent further fractures.

BACKGROUND:Many individuals with chronic obstructive pulmonary disease (COPD) experience frequent hospitalization and readmissions, which is burdensome on the health system. This study aims to investigate factors associated with unplanned readmissions and mortality following a COPD-related hospitalization over a 12-month period in Australia, focusing on mental disorders and accounting for the acute phase of the COVID-19 pandemic. METHODS:A retrospective cohort study using linked hospitalization and mortality records identified individuals aged ≥40 years who had at least one hospital admission with a principal diagnosis of COPD between 2014 and 2020 in New South Wales, Australia. A semi-competing risk analysis was conducted to examine factors associated with unplanned readmission and mortality. RESULTS:Adults with a mental disorder diagnosis, specifically anxiety, had a higher risk of 12-month unplanned readmission. Individuals with anxiety and dementia also had a higher risk of mortality pre- and post-unplanned readmission. Individuals who were admitted during the acute phase of the COVID-19 pandemic period had lower risk of unplanned readmission, but higher risk of mortality without unplanned readmission. CONCLUSION:Interventions aimed at reducing admissions should consider adults living with mental disorders such as anxiety or dementia to improve healthcare delivery and health outcomes for individuals living with COPD.

Objective This study aimed to examine group-based trajectories of hospital service use by people with chronic kidney disease (CKD) in the last 12months of life. Methods A retrospective cohort study was conducted using hospital admission and mortality data in New South Wales, Australia. Individuals aged ≥18years who were hospitalised during 2014-2021 and who died during 2015-2021 were included. A group-based trajectory analysis was conducted including all-cause admissions and unplanned-only admissions. Multinomial logistic regression examined predictors of trajectory group membership. Results There were 10,653 adults who had at least one CKD hospital admission 12months prior to death. Four group-based trajectories of hospital service use were identified for all-cause admissions (i.e. Very-Low, Low, Moderate, High) and three group-based trajectories for unplanned-only admissions (i.e. Low, Moderate, High). The study identified associations between frequent hospitalisations and key patient characteristics and health conditions. Individuals in the High hospitalisation group were more likely to have cancer (OR 4.55; 95% CI: 2.54-8.16). Additionally, the High unplanned hospitalisation group showed increased likelihoods of being adults aged 18-64years (OR 1.94; 95% CI: 1.32-2.84) and having diagnosis of congestive heart failure (OR 1.80; 95% CI: 1.26-2.55), cancer (OR 2.25; 95% CI: 1.49-3.40), mental disorders (OR 1.88; 95% CI: 1.35-2.62) or smoking (OR 2.01; 95% CI: 1.49-2.70) compared with the Low hospitalisation group. Conclusions Group-based trajectory analysis revealed specific patterns in hospital service usage. Understanding these patterns helps in devising targeted strategies to decrease unplanned hospitalisations among these high-risk patients.

Objective To investigate the association between patient-reported experiences with new medication discharge counselling and readmission to hospital or emergency department (ED) visits within 30 days of discharge. Methods A retrospective cross-sectional study of patient-reported experiences from 8715 patients who reported being prescribed a new medication at discharge from a public hospital. Completeness of medication counselling was assessed based on (i) explanation of medication purpose, (ii) explanation of medication side effects, (iii) patient involvement in decision to use medication, (iv) provision of contradictory information. Multilevel models were used to estimate self-reported 30-day readmission or ED visit related to care received using adjusted odds ratios (AORs). Results Patients who were explained medication purpose were half as likely to report a readmission (AOR 0.54, 95%CI 0.31-0.93) or ED visit (AOR 0.65, 95%CI 0.48-0.87) within 30 days of discharge. Conversely, those who reported receiving contradictory information were more likely to report a readmission (AOR 1.62, 95%CI 1.16-2.26) and ED visit (AOR 1.82, 95%CI 1.41-2.34). Conclusion Patients who reported receiving comprehensive counselling on new medications were less likely to report being readmitted or visiting an ED within 30 days of discharge.

Background Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation. Methods Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders ( n = 19), Agency for Clinical Innovation ( n = 11), and Ministry of Health ( n = 21) staff. Results The program’s audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy. Conclusions Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Objective Large-scale, multisite hospital improvement initiatives can advance high-quality care for patients. Implementation support is key to adoption of change in this context. Strategies that foster collaboration within local teams, across sites and between initiative developers and users are important. However not all implementation strategies are successful in all settings, sometimes realising poor or unintended outcomes. Our objective here is to develop guiding principles for effective collaborative implementation strategies for multi-site hospital initiatives.Design Mixed-method realist evaluation. Realist studies aim to examine the underlying theories that explain differing outcomes, identifying mechanisms and contextual factors that may trigger them.Setting We report on collaborative strategies used in four multi-site initiatives conducted in all public hospitals in New South Wales, Australia (n>100).Participants Using an iterative process, information was gathered on collaborative implementation strategies used, then initial programme theories hypothesised to underlie the strategies’ outcomes were surfaced using a realist dialogic approach. A realist interview schedule was developed to elicit evidence for the posited initial programme theories. Fourteen participants from 20 key informants invited participated. Interviews were conducted via Zoom, transcribed and analysed. From these data, guiding principles of fostering collaboration were developed.Results Six guiding principles were distilled: (1) structure opportunities for collaboration across sites; (2) facilitate meetings to foster learning and problem-solving across sites; (3) broker useful long-term relationships; (4) enable support agencies to assist implementers by giving legitimacy to their efforts in the eyes of senior management; (5) consider investment in collaboration as effective well beyond the current projects; (6) promote a shared vision and build momentum for change by ensuring inclusive networks where everyone has a voice.Conclusion Structuring and supporting collaboration in large-scale initiatives is a powerful implementation strategy if contexts described in the guiding principles are present.

Importance:Psychometrically robust patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are critical to evaluating quality and performance across health services and systems. However, the adoption and implementation of PROMs and PREMs remain a challenge in many countries. The aim of this guide is to support instrument selection and implementation to measure health system performance.Observations:The guide is split into 3 step-by-step sections. Step 1: Knowing What to Measure discusses what PROMs and PREMs capture and how they differ from related instruments. Step 2: Choosing the Right Instrument describes the critical psychometric properties of validity, reliability, and responsiveness, and provides resources to support instrument selection and evaluation. Step 3: Mitigating Potential PROM and PREM Implementation Barriers outlines key barriers and supports for instrument implementation at system, service, and individual levels.Conclusions and Relevance:This guide aims to provide practical resources for the identification of psychometrically robust PROMs and PREMs, as well as support for their implementation to drive improvements across health systems globally.

This study quantifies the association between patient reported measures (PRMs) and readmission to inform efforts to improve hospital care. A retrospective, cross-sectional study was conducted with adults who had chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF) and were admitted for acute care in a public hospital in New South Wales, Australia for any reason (n = 2394 COPD and 2476 CHF patients in 2018-2020). Patient- level survey data were linked with inpatient data for one year prior to risk-adjust outcomes and after discharge to detect all cause unplanned readmission to a public or private hospital. Ninety-day readmission rates for respondents with COPD or CHF were 17% and 19%. Crude rates for adults with COPD were highest among those who reported that hospital care and treatment helped "not at all" (28%), compared to those who responded, "to some extent" (20%) or "definitely" (15%). After accounting for patient characteristics, adults with COPD or CHF who said care and treatment didn't help at all were at twice the risk of readmission compared to those who responded that care and treatment helped "definitely" (Hazard ratio for COPD 1.97, CI: 1.17-3.32; CHF 2.07, CI 1.25-3.42). Patients who offered the most unfavourable ratings of overall care, understandable explanations, organised care, or preparedness for discharge were at a 1.5 to more than two times higher risk of readmission. Respect and dignity, effective and clear communications, and timely and coordinated care also matter. PRMs are strong predictors of readmission even after accounting for risk related to age and co-morbidities. More moderate ratings were associated with attenuation of risk, and the most positive ratings were associated with the lowest readmission rate. These results suggest that increasing each patient's positive experiences progressively reduces the risk of adults with chronic conditions returning to acute care.

In NSW, approximately 200 000 patients undergo elective surgery in approximately 90 public hospitals each year. It's population-based and comprehensive information system has been used to support quarterly public reporting of surgical activity, performance, and waitlists.1 Since 2020, each pandemic wave has presented key challenges that have necessitated customized responses informed by the preceding wave's experience (Table 1). As the pandemic became endemic, NSW saw high numbers of Omicron cases with concurrent relaxation of public health restrictions. Despite the lifting of restrictions, the health system continues to see the lowest percentage of patients seen on time, and the highest number of patients waiting longer than clinically recommended, than at any time on record. With more than 100 000 people on the waiting list and new additions to the waiting list still not reaching a normal rate, clinicians, managers and policymakers must navigate the way forward to mitigate what maybe an impending public health crisis of delayed surgical care. Innovation is essential given staff furloughing and a baseline level of beds required for patients with COVID limits capacity to surge beyond usual surgical activity, and the ongoing risk of future pandemic waves. Interrogation of the health system data provides an opportunity to analyse the impact and trends of repeated suspensions, slowdowns, and surges in elective surgery activity, so vulnerable groups can be monitored, and inequity addressed (Figs. 1-4). This paper presents a systems level reflection on emerging trends over the course of the pandemic to enable surgical systems to anticipate, monitor, respond and learn to support health system resilience, maintain surgical standards and mitigate workforce burnout.2-4 Alpha Suspension 25th March 2020. Resumption gradually increased from 18th May to July 2020 Delta Suspension 2nd August 2021 Resumption 5th October to 15th November Omicron (BA1 and 2) Suspension 10th January with Resumption 7th February in Private and 7th March in Public sector Similar to the reported experience of Victoria,5 the pandemic forced the surgical community in NSW to explore new avenues to plan, organize and evaluate services (Table 1). This required interdisciplinary leadership between clinicians, managers, and policy makers across Australia. In NSW, based on long term engagement through the Surgical Services Taskforce and the establishment of strong state-wide surgical governance committees, these established networks were scaled into a Surgical Community of Practice. Exchange between other specialty communities also occurred through the newly established Clinical Council. Academics with clinical and policy experience were engaged through the Critical Intelligence Unit6 for rapid evidence reviews. The RACS state committee was leveraged to rapidly disseminate information to all fellows (public and private), provide targeted training (e.g., PPE and Value Based Care) and support state-based examinations. The collaborative network was also engaged with international interdisciplinary network to draw on their expertise to support system agility. Such coordinated collaboration between clinicians and administrators locally enabled rapid redesign and dissemination of information to coordinate state and local responses which were able to be adapted to the challenges presented by each variant (Table 1). Importantly, additions for urgent procedures remained relatively stable with small surges in the months after slowdowns and suspensions. This is consistent with trends seen in other states.7 There was general consensus by the taskforce to prioritize urgent cat 1 and patients in cat 2 at risk of significant deterioration, and Cat 1 for the most part were performed within clinically recommended guidelines. The evolving size of a waiting list is impacted by changes in activity, but also an area which is less frequently monitored; the rate at which new patients are added. In NSW stay at home orders resulted in significant slowdowns in activity due to changes in behaviour patterns which occurred prior to directives to suspend non-urgent surgery(Fig. 2). Suspension of non-urgent surgery also impacted rate of new patients added to the waiting list which was further exacerbated by the duration of disruption.8 This may have resulted from clinical decision-making (e.g., hesitancy to add patients to the list), clinical work practices (e.g., reduced hours due to furlough or safety concerns), disrupted referral patterns (e.g., primary care network focus on vaccination or reduced surgical outpatient volume due to COVID safe practices), healthcare seeking behaviours (e.g., increased fear of accessing care due to high community prevalence of COVID-19) and public policy (e.g. stay at home orders). During the surge in elective surgery following the alpha wave, activity reached record levels within months and continued in all subsequent quarters until the arrival of the Delta variant wave in mid-2021.4, 8 During that surge, net migration was negligible suggesting rates of surgery per capita were higher than ever (Fig. 1). However, the impact of Delta and Omicron on waiting time for non-urgent surgery has been long lasting and the rate of growth in overdue patients has accelerated with each subsequent slowdown. Concerningly, the rate of additions at the current time has not returned to pre-pandemic levels,8 which means that the system has not yet realized the full impact of the true backlog. This has had an impact on semi-urgent surgery as the number and proportion of overdue semi-urgent patients has grown rapidly after multiple slowdowns (Fig. 3).4 The impact of this on specific specialties is starting to emerge identifying vulnerable groups.9 The long-term impact of this on the community is yet to be fully understood but it requires careful monitoring and attention by clinicians, managers and policy makers. With each wave and restriction, it is important that a nuanced policy approach be implemented (detailed in Table 1). For instance, geographically circumscribed suspensions during the delta wave resulted in elective surgery continuing unabated in unaffected regions (Fig. 2).4 During Omicron, targeted suspensions of surgery requiring overnight stays was relatively effective at ensuring day procedures continued, and models of outpatient and day only procedures and care were expanded. Collaborative and contractual arrangements between public and private hospitals were effective at managing demand and waiting lists. However, sustained surge strategies strained resources over time, and despite targeted strategies, geographic and speciality-specific inequities in access continue. High-volume specialties such as orthopaedics, otolaryngology, ophthalmology, and general surgery procedures have been impacted disproportionately. Recovery has also varied by specialty and has been slowest in orthopaedics suggesting that specialties with a lower case-mix of day procedures recover slower (Fig. 4).4 Rapid evolution of new models of care for surgical practice are critical to manage each specialty need. High volume specialties are more vulnerable and where feasible must adopt day surgery models of care while also improving pre-habilitation and rehabilitation services (e.g., Enhancing Recovery after Surgery and hospital in the home).10 Changes to surgical practices such as performing day cases first on the list, changes to session length, twilight sessions and procedure specific lists should also be considered. Expanding the value-based approach to support a patient-centred surgical approach will also help improve quality and appropriateness.10, 11 Several issues challenge the resilience of rural and regional areas compared to metropolitan centres. For example, funding support to engage public-private partnerships seem to provide more support in metropolitan areas where more private hospitals are located. While, suspensions limited to metropolitan areas during the Delta wave ensured that elective surgery in regional and rural areas continued throughout 2021 (Fig. 2), some towns close to state borders were impacted by conflicting state policies and travel restrictions on clinicians and patients reducing efficiency for surgical services. This underscores the need for a national approach to crisis management to mitigating disruption to surgical services in border regions. Metropolitan centres have different types of challenges. For example, a higher transmission of the Delta wave was seen in areas of Sydney with higher population density, higher proportions of essential workers, lower health literacy and larger cultural and linguistic diversity. While these areas often experience a higher demand on the public system, they also have less private hospital availability. Retaining stability of urgent surgical care during crisis demand strong collaborations between public and private hospitals and between local health districts—working together as one network to innovate and serve local communities. To maintain resilience, a shared strategy for addressing overdue patients requires a similar commitment as a network. While surgical services are run by state health services, surgical training and workforce supply is done by the college and specialist societies at a federal level. Maintaining this standard is vital but long-term variation to surgical services may create variability in the quality of surgical training in different states. Thus, collaboration with state health services and the Royal Australasian College of Surgeons (RACS) is essential to allow sustainability of high-quality workforce supply that is transferable between different jurisdictions. Surgical safety and outcomes rely on evidence-based standards and protocols that are implemented across the system. While the Alpha wave allowed the implementation of state-wide guidelines, the Delta wave needed a more nuanced approach to policies and protocols to preserve surgical services where possible. Geographic variance in performance between each hospital, rapid changes in policy and practice and uncertainty of the future creates stress. To mitigate this, NSW Health implemented numerous strategies to protect the health workforce and hospitalized patients in ways that impacted elective surgery activity and performance in response to policy directives (Table 1). An ongoing communication strategy and transparency of data is critical to mitigate future workforce burnout. Resuming elective surgery is more difficult than suspending it12 because of a cumulative effect of system changes that have to be translated over diverse hospital practices as well as the complex interaction of care seeking and care giving behaviour during periods of uncertainly. These findings highlight that there are likely to be disruptions across the patients' referral pathways that will appear in recovery phases. Surge planning in health systems therefore need to accommodate for (1) a backlog of patients already waiting for surgery, (2) an increase in rate of additions as more patients feel safe to present for care and (3) an increase in presentation of more complex pathology13 that will utilize more resources. This can also compound workforce burnout during surgical surge. The role of surgical triage12 and the need to empower clinician judgement is critical to prevent complications. A key lesson from this pandemic is to avoid planning a definitive strategy over the medium term which lacks flexibility but communicate the strategy in place at the time to remain agile. Strong clinical engagement process needs to be used to support decision-making. The pandemic and its influence on the health system has continually evolved, driven by the virus, society's use or evolving tolerance of public policies (e.g., stay at home orders), population characteristics (e.g., vaccination rates) and the evolving decisions of clinicians and health-seeking behaviours of citizens. Accordingly, leaders of resilient health and surgical systems need to understand the policy and practice contexts and levers at their disposal and the local factors that drive their suitability and impact. While the impact of COVID-19 has reached an endemic state, its impact on surgery continues to worsen demanding ongoing innovation and agility which only possible with collaboration. We thank colleagues for innovative ideas, thoughtful reflections, and engaging leadership. We thank the Bureau of Health Information for their analyses of data. Open access publishing facilitated by The University of Sydney, as part of the Wiley - The University of Sydney agreement via the Council of Australian University Librarians.

BACKGROUND:Total knee and total hip replacement are common and resource-intensive procedures. Complications are associated with worse outcomes and can add to the health care costs, particularly if associated with readmission. The aims of this study were to inform quality improvement by reporting on the extent of variation in readmissions across public hospitals and investigating the association between hospital volume and readmissions.METHODS:This retrospective population-based cohort study used linked, admitted patient data for a census of all admissions to public and private hospitals. Adults who had an acute hospitalization for total knee or total hip replacement elective surgery and were discharged alive between 1 July 2015 and 30 June 2018 were included. Hospital volumes and risk standardized readmission ratios were calculated, and readmissions included acute hospitalizations following discharge and returns to acute care from non-acute settings within 60 days.RESULTS:In 2015-2018, one in 10 patients were readmitted following total knee or total hip replacement (11.9 and 10.6 per 100 hospitalizations) an increase of 4.9% and 13.1% respectively, compared to 2012-2015. The majority of hospitals had risk standardized readmission ratios no different than expected. The median annual hospital volume was 170 total knee (interquartile range 116-247) and 93 total hip (interquartile range 61-141) procedures with no evidence of a meaningful association between hospital volume and readmissions.CONCLUSION:Readmissions rates for total knee and total hip replacements are increasing. While hospital volume varies, it was not associated with readmission after adjusting for risk factors and any non-linear association.

Studies of clinical effectiveness have demonstrated the many benefits of programmes that avoid unnecessary hospitalisations. Therefore, it is imperative to examine the factors influencing implementation of these programmes to ensure these benefits are realised across different healthcare contexts and settings. Numerous factors may act as determinants of implementation success or failure (facilitators and barriers), by either obstructing or enabling changes in healthcare delivery. Understanding the relationships between these determinants is needed to design and tailor strategies that integrate effective programmes into routine practice. Our aims were to describe the implementation determinants for hospital avoidance programmes for people with chronic conditions and the relationships between these determinants. An electronic search of four databases was conducted from inception to October 2019, supplemented by snowballing for additional articles. Data were extracted using a structured data extraction tool and risk of bias assessed using the Hawker Tool. Thematic synthesis was undertaken to identify determinants of implementation success or failure for hospital avoidance programmes for people with chronic conditions, which were categorised according to the Consolidated Framework for Implementation Research (CFIR). The relationships between these determinants were also mapped. The initial search returned 3537 articles after duplicates were removed. After title and abstract screening, 123 articles underwent full-text review. Thirteen articles (14 studies) met the inclusion criteria. Thematic synthesis yielded 23 determinants of implementation across the five CFIR domains. ‘Availability of resources’, ‘compatibility and fit’, and ‘engagement of interprofessional team’ emerged as the most prominent determinants across the included studies. The most interconnected implementation determinants were the ‘compatibility and fit’ of interventions and ‘leadership influence’ factors. Evidence is emerging for how chronic condition hospital avoidance programmes can be successfully implemented and scaled across different settings and contexts. This review provides a summary of key implementation determinants and their relationships. We propose a hypothesised causal loop diagram to represent the relationship between determinants within a complex adaptive system. PROSPERO 162812

Introduction Postsurgical sepsis is a common complication, accounting for one-third of all sepsis cases and associated with higher risk of mortality. Objectives and Approach The Bureau of Health Information (BHI) in New South Wales (NSW), Australia produces independent reports and information about the performance of the healthcare system. Our report investigates the rate of sepsis within 30-days following surgery, and explores variation in risk standardised postoperative sepsis across NSW public hospitals. The study cohort and outcome definitions were drawn from existing international patient safety indicators, modified for appropriate use with Australian linked hospital and mortality data to identify patients transferred, or readmitted to any NSW public or private hospital with postoperative sepsis. Fine and Gray competing risks regression models were used to calculate risk-adjusted rates, and funnel plots were used to identify outliers. Results Rate of 30-day postoperative sepsis was 0.9% among 66,143 adult elective surgeries that met the inclusion criteria during January 2015 to December 2017. Results showed around 33% of post-operative sepsis were identified as occurring during either a transfer or readmission to hospital. Hospital-level unadjusted rates of postsurgical sepsis ranged from 0% to 2% across more than 80 NSW public hospitals. The majority of hospitals (94%) had postoperative sepsis results lower or no different than expected. Conclusion/Implications We explored postoperative sepsis to help understanding of sepsis risk during the follow up period. Results showed a considerable number of postoperative sepsis cases would not have been identified without the use of linked data. Results on hospital risk standardised 30-day postoperative sepsis may prove useful as a screening tool for quality improvement in this area.

Introduction Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond ‘what works’ towards more nuanced understanding of ‘what tends to work for whom under which circumstances’. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts. Methods and analysis This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context–mechanism–outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed. Ethics and dissemination Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.