RATIONALE:The demand for health services to deliver hospital-based care has increased due to an ageing population, more complex healthcare needs, comorbidities, and increasing healthcare costs. Nurse-physician substitution can improve access to care for patients who may otherwise have a significant wait for review by a physician. OBJECTIVES:The main objective of this review was to examine the impact of substituting nurses for physicians in the hospital setting (hospital inpatient units and outpatient clinics) on patient outcomes, process of care outcomes, and economic outcomes. The secondary objectives of this review were to assess whether the effects of nurse-physician substitution differ according to healthcare setting (low- and middle-income countries (which included low-income, lower middle-income, and upper middle-income countries) versus high-income countries), patient type, patient disease, intervention type (inpatient care, nurse-led clinics, role substitution, and task substitution), nurse grade, additional training, level of responsibility, and mode of substitution for nurse-led clinics (telephone/telehealth, partial substitution, enhanced substitution, and full substitution). SEARCH METHODS:We searched CENTRAL, MEDLINE, Embase, NHSEED, CINAHL, ProQuest, two citation indexes, and two trial registries. We also conducted handsearches, reference checking, and contacted study authors to identify eligible studies. We searched five grey literature databases and contacted experts relevant to the review area. The evidence is current to 25 June 2024. ELIGIBILITY CRITERIA:We included randomised controlled trials of both individual and cluster design that compared the effects of care delivered by a nurse to that delivered by a physician on patient, process of care, and economic outcomes. We included care of inpatients or outpatients in hospital settings. OUTCOMES:Our critical outcomes were mortality, patient safety events, and clinical outcomes. Important outcomes were quality of life, self-efficacy, relative performance of practitioner, and direct costs. RISK OF BIAS:We assessed the risk of bias using the Cochrane RoB 2 tool. SYNTHESIS METHODS:We synthesised results for six outcomes (70 studies) using meta-analysis. We calculated odds ratios (OR) or risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes, and standardised mean differences (SMD) or mean differences (MD) with 95% CI for continuous outcomes. Data for clinical outcomes and relative performance of practitioner were stratified, and direct costs were summarised narratively. We assessed the certainty of evidence using GRADE for all outcomes. INCLUDED STUDIES:We included 80 parallel-group single or multi-site randomised studies and two cross-over single-site randomised studies. There were 28,041 participants with study sample sizes ranging from 7 to 1907 participants. Studies included specialist nurses, advanced nurse practitioners, and registered nurses substituting for junior and senior doctors across a range of specialties, including: cancer, cardiology, dermatology, endocrinology, gastroenterology, general medical, neonatology, neurology, obstetrics/gynaecology, ophthalmology, rheumatology, and respiratory. Nurses practised autonomously or under the supervision of a doctor, sometimes using protocols and sometimes providing care for specific groups of patients. Most studies lasted for 12 months, with two studies lasting up to five years. The studies were carried out worldwide, with the majority being conducted in the UK (39%). Seventy-two studies were conducted in high-income countries. We judged 34% of the studies as having low risk of bias, and 46% as having some concerns. SYNTHESIS OF RESULTS:Meta-analyses showed there is probably little to no difference between nurse and physician care in mortality (RR 1.03, 95% CI 0.87 to 1.21; I² = 0%; 19 studies, 8239 participants; moderate-certainty evidence), quality of life (SMD 0.10, 95% CI -0.04 to 0.23; I² = 65%; 22 studies, 5246 participants; moderate-certainty evidence), and self-efficacy (SMD 0.01, 95% CI -0.06 to 0.09; I² = 0%; 11 studies, 3022 participants; moderate-certainty evidence), and that there may be little to no difference in patient safety events (RR 0.92, 95% CI 0.84 to 1.01; I² = 9%; 31 studies, 14,437 participants; low-certainty evidence). We did not pool results for clinical outcomes overall (36 studies, 5177 participants), but found there may be little to no difference between nurse-physician substitution and physician-led care for most clinical outcomes. However, for a small number of outcomes, nurse-physician substitution may result in improvements in clinical outcomes. We did not pool results for relative performance of practitioner overall (22 studies, 13,818 participants), and found that results for some outcomes may favour nurse-physician substitution; some may favour physician-led care; and for several outcomes there may be little to no difference between the two. The certainty of evidence was low for direct costs. A narrative synthesis of direct costs (36 studies, 15,230 participants) showed 17 studies reporting reduced costs when physicians were substituted with nurses, with nine studies reporting increased costs owing to longer consultations, referrals, and drug prescription. The risk of bias was generally low across studies. AUTHORS' CONCLUSIONS:In our review, we found little to no difference between nurse-physician substitution and physician-led care. Although nurse-physician substitution may result in better outcomes in certain cases, the evidence is uncertain. In considering nurse-physician substitution as a solution to physician shortages, we also need to consider its impact on the nursing workforce. FUNDING:No financial support was received. REGISTRATION:Protocol (2020) DOI:10.1002/14651858.CD013616.

Background and Objectives: Atrial fibrillation (AF) is a common arrhythmia that may adversely affect the quality of life (QoL). Several factors could be associated with the QoL among patients with AF; however, evidence regarding these factors is still limited and controversial. Therefore, this study aimed to identify the level of QoL and its associated factors among Jordanian patients with AF. Subjects and methods: A case study design was implemented. A sample of 620 participants were recruited from 28 outpatient clinics registered in the Jordan atrial fibrillation registry AF (JoFIB). Data on QoL were gathered through the self-reported Atrial Fibrillation Effect on Quality-of-life tool (AFEQT). A QoL questionnaire was validated in this population before starting this study. The cardiac nurse then provided the research assistant with data relating to patients’ characteristics and associated comorbidities. Results: The overall AFEQT scores were positively skewed (median 21.3, IQR: 14.4–31.9). This pattern was reflected for the AFEQT sub-scales ‘Symptoms’ (20.8, 8.3–33.3), ‘Daily activities’ (16.7, 10.4–27.1), and ‘Treatment concerns’ (27.8, 19.4–41.7), whereas ‘Treatment satisfaction’ was negatively skewed (91.7, 83.3–91.7). Patients in the higher quartiles, indicating a better QoL, tended to be younger and were less likely to experience dyslipidemia, stroke, pulmonary hypertension, or other comorbidities. Over 90% of patients were currently experiencing AF, and patients with a better QoL tended to be less likely to be currently experiencing AF and more likely to have had their latest episode of AF more than a month ago (compared to less than a month ago). Age, BMI, dyslipidemia, heart failure, COPD, CAD, history of ablation, and the use of anticoagulants were significantly associated with the overall AFEQT score (R2 = 0.278). Conclusions: This study demonstrates that AF Jordanian patients had low levels of QoL. Patients in higher quartiles for the overall AFEQT score were younger, with fewer disease comorbidities and less experience of current AF episodes. Several modifiable and non-modifiable factors were associated with QoL in AF patients. Age, BMI, dyslipidemia, heart failure, COPD, CAD, history of ablation, and the use of oral anticoagulants were significantly associated with the overall AFEQT score. Healthcare providers should target these factors as indicators or interventions for which QoL is continuously monitored.

This umbrella review aimed to examine and synthesize qualitative studies that explored the barriers and facilitators of advance care planning for persons with dementia, their families, and their healthcare professionals and caregivers.The modified umbrella review approach developed by the Joanna Briggs Institute was followed. Five major English databases were searched.Four reviews based on 38 primary qualitative studies were included. The methodological quality of the included reviews was moderate to high. The synthesis yielded 16 descriptive themes and five analytical themes: making the wishes/preferences of persons with dementia visible; constructive collaboration based on stakeholders having positive relationships; emotional chaos in facing end-of-life substitute decision-making; initiating the advance care planning process; and preparedness and commitment of healthcare providers to advance care planning.Comprehensive and workable strategies are required to overcome complex and interrelated barriers involving not only healthcare professionals but also organizational and systemic challenges.

Aims This review aimed to investigate the effectiveness of nurse-led interventions vs. usual care on hypertension management, lifestyle behaviour, and patients' knowledge of hypertension and associated risk factors. Methods A systematic review with meta-analysis was conducted following Joanna Briggs Institute (JBI) guidelines. MEDLINE (Ovid), EmCare (Ovid), CINAHL (EBSCO), Cochrane library, and ProQuest (Ovid) were searched from inception to 15 February 2022. Randomized controlled trials (RCTs) examining the effect of nurse-led interventions on hypertension management were identified. Title and abstract, full text screening, assessment of methodological quality, and data extraction were conducted by two independent reviewers using JBI tools. A statistical meta-analysis was conducted using STATA version 17.0. Results A total of 37 RCTs and 9731 participants were included. The overall pooled data demonstrated that nurse-led interventions may reduce systolic blood pressure (mean difference -4.66; 95% CI -6.69, -2.64; I-2 = 83.32; 31 RCTs; low certainty evidence) and diastolic blood pressure (mean difference -1.91; 95% CI -3.06, -0.76; I-2 = 79.35; 29 RCTs; low certainty evidence) compared with usual care. The duration of interventions contributed to the magnitude of blood pressure reduction. Nurse-led interventions had a positive impact on lifestyle behaviour and effectively modified diet and physical activity, but the effect on smoking and alcohol consumption was inconsistent. Conclusion This review revealed the beneficial effects of nurse-led interventions in hypertension management compared with usual care. Integration of nurse-led interventions in routine hypertension treatment and prevention services could play an important role in alleviating the rising global burden of hypertension. Registration PROSPERO: CRD42021274900

Objectives This study aimed to compare clinical outcomes for patients admitted to Hospital in the Home (HITH) and traditional (bricks-and-mortar) hospitals and explore patient and carer experiences. Methods A mixed methods approach including triangulation of quantitative and qualitative data was used. Quantitative outcomes were compared using augmented inverse propensity weighting to adjust for differences in patient characteristics between groups. Qualitative data was collected by focus groups and interviews and analysed using reflexive thematic analysis. The study took place in metropolitan Adelaide and one adjacent regional health network in 2020-22. Participants were patients discharged from either hospital setting with 1 of 22 eligible diagnoses. Hospital administrative data informed a comparison of outcomes that included mortality, rate of emergency department re-presentations and re-admissions, length of stay and incidence of complications. Results Patients treated in HITH were less unwell than traditional hospital patients. There were no safety or quality concerns identified in the clinical outcomes. Of 2095 HITH patients, the in-patient mortality rate was 0.2%, and 2.3% experienced a return to a bricks-and-mortar hospital during the HITH admission. For HITH patients, the mortality rate after 30 days was lower (-1.3%, 95% CI -2 to -0.5, P = 0.002), as were re-presentations in 28 days (-7.2%, 95% CI -9.5 to -5, P < 0.0001), re-admissions in 28 days (-4.9%, 95% CI -6.7 to -3.2, P < 0.001) and complications (-0.6%, 95% CI -0.8 to -0.5, P < 0.001). Interviews of 35 patients and six carers found that HITH was highly accepted and preferred by patients. HITH was perceived to free up resources for other, more acutely unwell patients. Conclusions HITH was preferred by patients and at least as effective in delivering quality health care as a traditional hospital, although the potential for unobserved confounding must be acknowledged.

BACKGROUND:It is uncertain if patient's characteristics are associated with complaints and claims against doctors. Additionally, evidence for the effectiveness of remedial interventions on rates of complaints and claims against doctors has not been synthesised. METHODS:We conducted a rapid review of recent literature to answer: Question 1 "What are the common characteristics and circumstances of patients who are most likely to complain or bring a claim about the care they have received from a doctor?" and Question 2 "What initiatives or interventions have been shown to be effective at reducing complaints and claims about the care patients have received from a doctor?". We used a systematic search (most recently in July 2023) of PubMed, Scopus, Web of Science and grey literature. Studies were screened against inclusion criteria and critically appraised in duplicate using standard tools. Results were summarised using narrative synthesis. RESULTS:From 8079 search results, we reviewed the full text of 250 studies. We included 25 studies: seven for Question 1 (6 comparative studies with controls and one systematic review) and 18 studies for Question 2 (14 uncontrolled pre-post studies, 2 comparative studies with controls and 2 systematic reviews). Most studies were set in hospitals across a mix of medical specialties. Other than for patients with mental health conditions (two studies), no other patient characteristics demonstrated either a strong or consistent effect on the rate of complaints or claims against their treating doctors. Risk management programs (6 studies), and communication and resolution programs (5 studies) were the most studied of 6 intervention types. Evidence for reducing complaints and medico-legal claims, costs or premiums and more timely management was apparent for both types of programs. Only 1 to 3 studies were included for peer programs, medical remediation, shared decision-making, simulation training and continuing professional development, with few generalisable results. CONCLUSION:Few patient characteristics can be reliably related to the likelihood of medico-legal complaints or claims. There is some evidence that interventions can reduce the number and costs of claims, the number of complaints, and the timeliness of claims. However, across both questions, the strength of the evidence is very weak and is based on only a few studies or study designs that are highly prone to bias.

Objectives: To perform an umbrella review of systematic reviews with meta-analyses (MAs) examining the effectiveness of comprehensive geriatric assessment (CGA) delivered within community settings to general populations of community-dwelling older people against various health outcomes.Design: Umbrella review of MAs of randomized controlled trials (RCTs).Setting and Participants: Systematic reviews with MAs examining associations between CGA conducted within the community and any health outcome, where participants were community-dwelling older people with a minimum mean age of 60 years or where at least 50% of study participants were aged & GE;60 years. Studies focusing on residential care, hospitals, post-hospital care, outpatient clinics, emergency department, or patients with specific conditions were excluded.Methods: We examined CGA effectiveness against 12 outcomes: not living at home, nursing home admission, activities of daily living (ADLs) and instrumental ADLs (IADLs), physical function, falls, selfreported health status, quality of life, frailty, mental health, hospital admission, and mortality, searching the MEDLINE/PubMed, Cochrane Library, CINAHL, Embase databases from January 1, 1999, to August 10, 2022. AMSTAR-2 was used to assess the quality of included systematic reviews, including risk of bias.Results: We identified 10 MAs. Only not living at home (combined mortality and nursing home admission) demonstrated concordance between effect direction, significance, and magnitude. Significant effects were more typically observed in earlier rather than later studies.Conclusion and Implications: Given the widespread adoption of CGA as a component of usual care within geriatric medicine, the lack of strong evidence demonstrating the protective effects of CGA may be indicative of a cohort effect. If so, future RCTs examining CGA effectiveness are unlikely to demonstrate significant findings. Future studies of CGA in the community should focus on implementation and adherence to key components. Trial registration: Study protocol registered in PROSPERO 2020 CRD42020169680.& COPY; 2023 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

In Australia, local health services with allocated budgets manage public hospital services for defined geographical areas. The authors were embedded in a local health service for around 2 years and undertook a range of local level economic evaluations for which three decision contexts were defined: intervention development, post-implementation and prioritisation. Despite difficulties in estimating opportunity costs and in the relevance of portfolio-based prioritisation approaches, economic evaluation added value to local decision-making. Development-focused (ex ante) economic evaluations used expert elicitation and calibration methods to synthesise published evidence with local health systems data to evaluate interventions to prevent hospital acquired complications. The use of economic evaluation facilitated the implementation of interventions with additional resource requirements. Decision analytic models were used alongside the implementation of larger scale, more complex service interventions to estimate counterfactual patient pathways, costs and outcomes, providing a transparent alternative to the statistical analyses of intervention effects, which were subject to high risk of bias. Economic evaluations of more established services had less impact due to data limitations and lesser executive interest. Prioritisation-focused economic evaluations compared costs, outcomes and processes of care for defined patient populations across alternative local health services to identify, understand and quantify the effects of unwarranted variation to inform priority areas for improvement within individual local health services. The sustained use of local level economic evaluation could be supported by embedding health economists in local continuous improvement units, perhaps with an initial focus on supporting the development and evaluation of prioritised new service interventions. Shared resources and critical mass are important, which could be facilitated through groups of embedded economists with joint appointments between different local health services and the same academic institution.

INTRODUCTION:There has been a growing call for drug and/or alcohol dependence to be managed as a chronic condition. The Flinders Chronic Condition Management Program (Flinders Program) was implemented in a drug and alcohol service in Australia in 2019-2022 to explore the feasibility of chronic condition management in outpatient clinics. Implementation involved: adaptation of the Flinders Program; adaptation of clinical procedures; training clinicians and managers; training Flinders Program Accredited Trainers; and system integration. This study aims to explore barriers and enablers to implementation. METHODS:A qualitative formative evaluation was undertaken. Data included implementation documents (n = 7), responses to open-ended questions in post-training surveys (n = 27), and focus groups and interviews with implementation staff, clinicians, managers and a trainer (n = 16). Data were analysed using the Consolidated Framework for Implementation Research in a 'coding reliability' approach to thematic analysis. RESULTS:Participants responded positively to the Flinders Program's philosophy, processes, tools and training. However, barriers were identified across three Consolidated Framework for Implementation Research domains: (i) outer setting (client suitability and incompatibility with external policies and incentives); (ii) characteristics of individuals (low self-efficacy); and (iii) inner setting (lack of system and workflow integration). DISCUSSION AND CONCLUSIONS:Executive support and systems integration are important for the implementation of the Flinders Program in drug and alcohol services. This needs to be achieved within externally mandated key performance indicators for outpatient services. Further research is needed to fully evaluate the potential of a chronic condition management framework in Australian outpatient drug and alcohol services.

Background The National Stroke Audit has been used to audit and provide feedback to health professionals and stroke care services in Australia since 2007. The Australian Stroke Clinical Registry was piloted in 2009 and numbers of hospitals participating in the registry are increasing. Considering the changing data landscape in Australia, we designed this study to evaluate the stroke audit and to inform strategic direction.Methods We conducted a rapid review of published literature to map features of successful data programmes, followed by a mixed-methods study, comprising national surveys and interviews with clinicians and administrators about the stroke audit. We analysed quantitative data descriptively and analysed open-ended survey responses and interview data using qualitative content analysis. We integrated data from the two sources.Results We identified 47 Australian data programs, successful programs were usually funded by government sources or professional associations and typically provided twice yearly or yearly reports.106 survey participants, 14 clinician and 5 health administrator interview participants were included in the evaluation. The Stroke Audit was consistently perceived as useful for benchmarking, but there were mixed views about its value for local quality improvement. Time to enter data was the most frequently reported barrier to participation (88% of survey participants), due to the large number of datapoints and features of the audit software.Opportunities to improve the Stroke Audit included refining Audit questions, developing ways to automatically export data from electronic medical records and capturing accurate data for patients who transferred between hospitals.Conclusion While the Stroke Audit was not perceived by all users to be beneficial for traditional quality improvement purposes, the ability to benchmark national stroke services and use these data in advocacy activities was a consistently reported benefit. Modifications were suggested to improve usability and usefulness for participating sites.

Many hospitals continue to use incident reporting systems (IRSs) as their primary patient safety data source. The information IRSs collect on the frequency of harm to patients [adverse events (AEs)] is generally of poor quality, and some incident types (e.g. diagnostic errors) are under-reported. Other methods of collecting patient safety information using medical record review, such as the Global Trigger Tool (GTT), have been developed. The aim of this study was to undertake a systematic review to empirically quantify the gap between the percentage of AEs detected using the GTT to those that are also detected via IRSs. The review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies published in English, which collected AE data using the GTT and IRSs, were included. In total, 14 studies met the inclusion criteria. All studies were undertaken in hospitals and were published between 2006 and 2022. The studies were conducted in six countries, mainly in the USA (nine studies). Studies reviewed 22 589 medical records using the GTT across 107 institutions finding 7166 AEs. The percentage of AEs detected using the GTT that were also detected in corresponding IRSs ranged from 0% to 37.4% with an average of 7.0% (SD 9.1; median 3.9 and IQR 5.2). Twelve of the fourteen studies found <10% of the AEs detected using the GTT were also found in corresponding IRSs. The >10-fold gap between the detection rates of the GTT and IRSs is strong evidence that the rate of AEs collected in IRSs in hospitals should not be used to measure or as a proxy for the level of safety of a hospital. IRSs should be recognized for their strengths which are to detect rare, serious, and new incident types and to enable analysis of contributing and contextual factors to develop preventive and corrective strategies. Health systems should use multiple patient safety data sources to prioritize interventions and promote a cycle of action and improvement based on data rather than merely just collecting and analysing information.

The concept of safety culture in healthcare-a culture that enables staff and patients to be free from harm-is characterized by complexity, multifacetedness, and indefinability. Over the years, disparate and unclear definitions have resulted in a proliferation of measurement tools, with lack of consensus on how safety culture can be best measured and improved. A growing challenge is also achieving sufficient response rates, due to "survey fatigue," with the need for survey optimisation never being more acute. In this paper, we discuss key challenges and complexities in safety culture assessment relating to definition, tools, dimensionality and response rates. The aim is to prompt critical reflection on these issues and point to possible solutions and areas for future research.

Background Conducting root cause analysis (RCA) is complex and challenging. The aim of this study was to better understand the experiences of RCA team members and how they value their involvement in the RCA to inform future recruitment, conduct and implementation of RCA findings into clinical practice. Methods The study was set in a health network in Adelaide, South Australia. A qualitative exploratory descriptive approach was undertaken to provide an in-depth understanding of team member’s experience in participating in an RCA. Eight of 27 RCA team members who conducted RCAs in the preceding 3-year period were included in one of three semi-structured focus groups. Thematic analysis was used to synthesise the transcribed data into themes. Results We derived four major themes: Experiences and perceptions of the RCA team, Limitations of RCA recommendations, Facilitators and barriers to conducting an RCA, and Supporting colleagues involved in the adverse event. Participants’ mixed experience of RCAs ranged from enjoyment and the perception of worth and value to concerns about workload and lack of impact. Legislative privilege protecting RCAs from disclosure was both a facilitator and a barrier. Concern and a desire to better support their colleagues was widely reported. Conclusions Clinicians perceived value in reviewing significant adverse events. Improvements can be made in sharing learnings to make effective improvements in health care. We have proposed a process to better support interviewees and strengthen post interview follow up.

AimsEvidence regarding the most effective and feasible videoconferencing group educational program for patients with heart failure is still equivocal. This study aimed to reach consensus about the structure, acceptability, and feasibility of videoconferencing for people with heart failure in Jordan that improves access to healthcare and clinical outcomes.MethodsThere were two Delphi survey studies of three rounds each. Delphi one survey involved 32 healthcare staff, experienced in heart failure clinical practice and telehealth, to obtain a consensus of opinion on a proposed group videoconferencing program for patients with heart failure. Delphi two involved seven staff of the information technology center, experienced in videoconferencing and using supporting applications, to obtain their consensus on the current capabilities of the healthcare system and patients about information technology. Descriptive statistics were used for each item to determine whether consensus was achieved or not. Items that received 80% disagreement or 80% agreement of participants were not presented for re-rating in the third round, while the items that scored varying degrees of agreement were presented for experts for re-rating.ResultsIn Delphi one a group of items reached consensus regarding structure, factors influencing, and effectiveness of the videoconferencing program. In Delphi two, the findings indicated that videoconferencing modality is applicable and feasible in Jordan.ConclusionThis is the first study that addresses the equivocal evidence for the design and implementation of heart failure videoconferencing programs. The framework of the current proposed program can be utilized as a guideline to test or develop a future videoconference program.

Background There is sufficient and consistent international evidence of issues reported by nurses working in single-bed room environments, requiring a design that is not only comfortable for patients but meets nurses working needs. This paper presents a comparison of nursing staff and patients experience prior to a move to 100% single-bed room hospital in 2016 (Stage 1) and actual experiences after the move in 2021 (Stage 2) in South Australia. Method Mixed method case study design. Survey sample of forty-two nursing staff; twelve patient interviews of their experiences of current environment and; thirteen nursing staff interviews of their experiences delivering nursing care in 100% single bed-room environment. Results Nurses and patients highlighted single-bed rooms contributed to patients’ privacy, confidentiality, dignity and comfort. As anticipated in Stage 1, nurses in Stage 2 reported lack of patient and staff visibility. This impacted workload, workflow and concern for patient safety. Conclusion Patient and nursing staff experiences are interdependent, and implications of single-bed room accommodation are complicated. Future impacts on the health system will continue to affect hospital design, which must consider nurses working needs and patient safety and comfort.

RATIONALE Increasing demand for hospital services can lead to overcrowding and delays in treatment, poorer outcomes and a high cost-burden. The medical ambulatory care service (MACS) provides out of hospital patient care, including diagnostic and therapeutic interventions for patients that require urgent attention, but which can be safely administered in the ambulatory environment. The programme is yet to be rigorously evaluated. AIMS/OBJECTIVES The aim of this study is to evaluate the impact of the MACS programme on emergency department (ED) presentations, hospital admissions, length-of-stay and health service costs from a health system perspective. METHOD We used a single group interrupted time series methodology with a multiple baseline approach to analyse the impact of the MACS clinic on ED presentations, hospital admissions, length-of-stay and cost outcomes for general practitioners (GP)-referred, ED-referred and ward-referred patients under two counterfactual scenarios: an increasing trend in health utilization based on preperiod predictions or a stabilization of utilization rates. RESULTS The time trend of hospital utilization differed after attending MACS for all three referral groups. The time trend for the GP-referred group declined significantly by 0.36 ED presentations per 100 patients per 30 days [95% confidence interval (CI): -0.52 to -0.2], while inpatient length of stay declined significantly by 1.56 and 3.70 days, respectively, per 100 ED-referred and ward-referred patients per 30 days (95% CI: -2.51 to -0.57 and -5.71 to -1.69, respectively). Under two different counterfactual scenarios, the predicted net savings for MACS across three patient groups were $78,685 (95% CI: $54,807-$102,563) and $547,639 (95% CI: $503,990-$591,287) per 100 patients over 18 months. CONCLUSION MACS was found to be cost-effective for GP and ward-referred groups, but the expected impact for ED-referred patients is sensitive to assumptions. Expansion of the service for GP-referred patients is expected to reduce hospitalizations the most and generate the largest net cost savings.