THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet
Surname or Family name: Caplan
First name: Gideon Other name/s: Avram
Abbreviation for degree as given in the University calendar: MD
School: Clinical School Prince of Wales Hospital Faculty: Medicine
Title: Alternatives to standard in-hospital care
Abstract 350 words maximum: (PLEASE TYPE)
The accompanying published articles submitted for the degree of Doctor of Medicine by publication focus on the rigorous evaluation of health services. They present the results of three non-randomized controlled trials and four randomized controlled trials that I initiated, conceived the ideas for, designed the hypotheses, employed a variety of people to carry out the data collection, and usually analysed and wrote up myself.
The papers examine various aspects of alternatives to standard in-hospital care, including providing Hospital in the Home: acute subacute or post-acute care at home and in residential aged care facilities; chronic care at home to prevent readmission; implementing Comprehensive Geriatric Assessment in the Emergency Department; and adding to the hospital workforce, using a team of volunteers to improve the care on the ward, thereby covering a large variety of older peoples’ contacts with the hospital system.
These studies have had a demonstrable major impact on the delivery of health services across Australia, and the ideas have been taken up overseas. There has been direct transfer of services based on these trials to other hospitals through the Australian Commonwealth Department of Health’s National Demonstration Hospitals Program , as well as systemic roll out by the NSW Department of Health.
These studies have advanced the field of health services research by demonstrating that improving the delivery of health services not only affects administrative outcomes by reducing length of stay and cost, but also has a measurable effect on health outcomes, such as reduced mortality and reduced complications, including delirium and wound infections, as well as increased patient satisfaction. Combining the two sets of data, health outcomes and economic evaluation, has assisted with more rapid dissemination.
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I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation.
I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstracts International (this is applicable to doctoral theses only).
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ORIGINALITY STATEMENT ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.’
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MD THESIS
Alternatives to standard in-hospital care
A/Prof Gideon A Caplan
Director, Post Acute Care Services
Director, Geriatric Medicine
Prince of Wales Hospital
Randwick NSW 2031
Sydney, Australia
COPYRIGHT STATEMENT ‘I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only). I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation.'
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AUTHENTICITY STATEMENT ‘I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format.’
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Table of Contents Page 1) Introduction 4
2) Publications
1. Caplan GA Lord SR Ward JA. The benefits of exercise in postmenopausal 55 women. Australian Journal of Public Health 1993; 17 (1): 23-26. 2. Lord SR Caplan GA Ward JA. Balance, reaction time, and muscle strength in 59 nonexercising older women: A pilot study. Archives of Physical Medicine and Rehabilitation 1993; 74 (8): 837-840. 3. Caplan GA Colagiuri R Lord SR Colagiuri S Ward JA. Exercise in older 62 people with type II diabetes maintains bone density despite weight loss. Australian Journal on Ageing 1995; 14 (2): 71-75. 4. Lord SR Caplan GA Colagiuri R Colagiuri S Ward JA. Sensori-motor 67 function in older persons with diabetes. Diabetic Medicine 1993; 10: 614-618. 5. Caplan GA Scane A Francis RM. Pathogenesis of vertebral crush fractures in 72 women. Journal of the Royal Society of Medicine 1994; 87: 200-202. 6. Caplan GA Brown A. Post acute care: can hospitals do better with less? 75 Australian Health Review 1997; 20: 43-54. 7. Brennan NJ Caplan GA. Attitudes to osteoporosis among elderly female 87 orthopaedic patients. Osteoporosis International 1999; 9: 139-143. 8. Lim K Wren B Jepson N Roy S Caplan GA. Hormone replacement therapy 92 and its effects on left ventricular wall thickness. American Journal of Cardiology 1999; 83: 1132-4. 9. Boxall A-m, Sayers A, Caplan GA. A cohort study of 7 day a week 95 physiotherapy on an acute orthopaedic ward. Journal of Orthopaedic Nursing 2004; 8: 96-102. 10. Henderson EJ, Caplan GA. Home sweet home? Community care for older 102 people in Australia. Journal of the American Medical Directors Association, 2008; 9(2): 88-94. 11. Caplan GA, Meller A. Home care for dying people. (Editorial) Journal of the 109 American Medical Directors Association, (in press) 12. Brown A Caplan G. A post-acute respiratory outreach service. Australian 111 Journal of Advanced Nursing 1997; 14: 5-11. 13. Boxall A-m Barclay L Caplan GA. Managing chronic obstructive pulmonary 118 disease in the community: a randomised controlled trial of home based pulmonary rehabilitation for elderly, housebound patients. Journal of Cardiopulmonary Rehabilitation 2005; 25: 378-385. 14. Caplan GA Brown A Crowe PJ Yap S-J Noble S. Reengineering the elective 126 surgical service of a tertiary hospital: a historical controlled trial. Medical Journal of Australia 1998; 169: 247-251. 15. Caplan GA Board N Paten A Tazelaar-Molinia J Crowe PJ Yap S-J Brown A. 131 The cost to the community of decreasing lengths of stay. Australian and New Zealand Journal of Surgery 1999; 69: 433-7. 16. Board N Caplan G. Implications of decreasing surgical length of stay, 136 Australian Health Review 2000; 23(2): 71-85. 17. Board N Caplan GA. Use of pathology services in re-engineered clinical 151 pathways. Journal of Quality in Clinical Practice 2000; 20: 24-9. 18. Henderson A, Caplan GA, Daniel A. Patient satisfaction: the Australian patient 157
1
perspective. Australian Health Review 2004; 27: 73-83. 19. Caplan GA Ward JA Brennan N Board N Coconis J Brown A. Hospital in the 167 Home: a randomised controlled trial. Medical Journal of Australia 1999; 170: 156-160. 20. Board N Brennan N Caplan GA. A randomised controlled trial of the costs of 172 hospital as compared with hospital in the home for acute medical patients. Australian and New Zealand Journal of Public Health 2000; 24(3):305-311. 21. Caplan GA, Coconis J, Woods J. Effect of Hospital in the Home treatment on 179 physical and cognitive function: a randomised controlled trial. Journal of Gerontology: Medical Sciences 2005; 60: 1035-1038. 22. Caplan GA, Coconis J, Sayers A, Board N. A randomised controlled trial of 183 Rehabilitation of Elderly and Care at Home Or Usual Treatment (The REACH OUT Trial). Age and Ageing 2006; 35: 60-65. 23. Caplan GA. Hospital in the home: a concept under question. (editorial). 191 Medical Journal of Australia 2006;184: 599-600. 24. Caplan GA. Does Hospital in the Home treatment prevent delirium? Aging 193 Health 2008; 4(1): 69-74. 25. Caplan GA, Meller A, Chan S, Squires B, Willett W. Advance Care Planning 199 and Hospital in the Nursing Home. Age and Ageing 2006; 35: 581-5. 26. Meller AE Caplan GA. Let someone else decide? Development of an advance 204 care planning service for nursing home residents with advanced dementia. Dementia 2009; 8(3): 391-406. 27. Caplan GA, Brown A, Croker WD, Doolan J. Risk factors for admission after 219 Discharge of the Elderly from the Emergency Department - The DEED Study. Age and Ageing 1998; 27:697-702. 28. Caplan GA, Croker WD, Brown A. Recognition of deficits of physical and 225 cognitive function in the elderly by medical staff in the emergency department. Emergency Medicine 1998; 10: 19-24. 29. Caplan GA, Williams A, Daly B, Abraham K. A randomised controlled trial of 231 comprehensive geriatric assessment and follow up after discharge of elderly from the Emergency Department - The DEED II study. Journal of the American Geriatrics Society 2004; 52: 1417-1423. 30. Wong DD, Wong RPC, Caplan GA. Self Rated Health in the unwell elderly 238 presenting to the Emergency Department. Emergency Medicine Australia 2007; 19: 196-202. 31. Caplan GA Harper E. Recruitment of volunteers to improve vitality in the 245 elderly (The REVIVE Study). Internal Medicine Journal 2007; 37: 95-100. 3) Appendices:
Editorials by others about my work
Hillman, KM. Restructuring hospital services. Medical Journal of Australia 1998; 251 169(5): 239. Montalto, M. Hospital in the home: take the evidence and run. Medical Journal of 252 Australia 1999; 170(4): 148-149. Hertogh CMPM. Advance care planning and the relevance of a palliative care 254 approach in dementia. Age Ageing 2006; 35: 553-4. Curricu lum vitae 257
2
Introduction
Executive Summary ...... 4 1. Orthogeriatrics – the Post-acute Orthopaedic Rehabilitation Service ...... 5 2. Post Acute Respiratory Outreach Service ...... 22 3. Reengineering of elective surgery ...... 28 4. Hospital in the Home ...... 34 5. Advance Care Planning ...... 43 6. Discharge of Elderly from the Emergency Department (DEED) ...... 46 7. Linked medical issues ...... 51
MD Thesis Introduction 3
Executive Summary
The accompanying published articles focus on the rigorous evaluation of health services. They present the results of three non-randomized controlled trials and four randomized controlled trials that I initiated, conceived the ideas for, designed the hypotheses, obtained the funding, employed a variety of people to carry out the data collection, and usually analyzed the results and wrote up myself. These studies have had a demonstrable major impact on the delivery of health services across Australia, and the ideas have been taken up overseas. There has been direct transfer of services based on these trials to other hospitals through the Commonwealth
Department of Health’s National Demonstration Hospitals Program , as well as systemic roll out by the NSW Department of Health.
These studies have advanced the field of health services research by demonstrating that improving the delivery of health services not only affects administrative outcomes such as length of stay and cost, but also has a measurable effect on health outcomes, such as reduced mortality and reduced complications such as delirium, as well as increased patient satisfaction.
I have additionally collected information that shows reduced costs, and both sets of data have assisted with more rapid dissemination.
All of the papers examine various aspects of alternatives to standard in-hospital care, including providing acute; subacute or post acute; and chronic care at home as well as in residential aged care facilities, covering the variety of older people’s contacts with the hospital system. In one paper I examined an addition to the hospital workforce, using a team of volunteers to improve the care on the ward.
MD Thesis Introduction 4
1. Orthogeriatrics – the Post-acute Orthopaedic Rehabilitation Service
1. Caplan GA Lord SR Ward JA. The benefits of exercise in postmenopausal women. Australian Journal of Public Health 1993; 17 (1): 23-
26. [Journal Impact Factor =1.556; Citations at 15/9/2009 = 20]
2. Lord SR Caplan GA Ward JA. Balance, strength and reaction time in non-exercising women: A pilot study. Archives of Physical Medicine and
Rehabilitation 1993; 74 (8): 837-840. [1.734; 59]
3. Caplan GA Colagiuri R Lord SR Colagiuri S Ward JA. Exercise in older people with type II diabetes maintains bone density despite weight loss.
Australian Journal on Ageing 1995; 14 (2): 71-75. [0.319; 1]
4. Lord SR Caplan GA Colagiuri R Colagiuri S Ward JA. Sensori-motor function in older persons with diabetes. Diabetic Medicine 1993; 10: 614-618.
[2.725; 34]
5. Caplan GA Scane A Francis RM. Pathogenesis of vertebral crush fractures in women. Journal of the Royal Society of Medicine 1994; 87: 200-
202. [1.356; 20]
6. Caplan GA Brown A. Post acute care: can hospitals do better with less?
Australian Health Review 1997; 20: 43-54. [0.476; 9]
7. Brennan NJ Caplan GA. Attitudes to osteoporosis among elderly female orthopaedic patients. Osteoporosis International 1999; 9: 139-143. [4.290; 7]
MD Thesis Introduction 5
8. Lim K Wren B Jepson N Roy S Caplan GA. Hormone replacement therapy and its effects on left ventricular wall thickness. American Journal of
Cardiology 1999; 83: 1132-4. [3.905; 28]
9. Boxall A-m, Sayers A, Caplan GA. A cohort study of 7 day a week physiotherapy on an acute orthopaedic ward. Journal of Orthopaedic Nursing
2004; 8: 96-102. [0.180; 0]
10. Henderson EJ, Caplan GA. Home sweet home? Community care for older people in Australia. Journal of the American Medical Directors
Association , 2008; 9(2): 88-94. [3.467; 0]
11. Caplan GA, Meller A. Home care for dying people. (Editorial) Journal of the American Medical Directors Association , (in press) [3.467;0]
My role in this research My early research into post acute care and issues arising from it, demonstrate my evolution as a researcher. The early studies, which were unfunded, are non-randomised. Initially I was focused directly on medical aspects of care for older orthopaedic patients such as osteoporosis and falls. My first two research projects (reported in papers 1-4) were in collaboration with
Steven Lord who was beginning his research on falls and balance while I examined how weight- bearing exercise could affect bone density. I conceived the studies and recruited the patients for papers 1 and 2, collected data and performed the bone density assessments, while Dr Lord performed his physiological balance assessments. Dr Ward was my head of department and
Prof Colagiuri and Mrs Colagiuri, who ran the Diabetes Centre, assisted us with recruitment of diabetic patients for studies 3 and 4.
MD Thesis Introduction 6
Paper 5 was written while I worked as a Geriatric Medicine Registrar in England, under the supervision of Professor Roger Francis. I collected the data, and analysed it with the assistance of Dr Andrew Scane. I wrote the paper. Paper 6 was written by me with critical intellectual input from Ann Brown. Paper 7 was written by my registrar, Dr Nicholas Brennan, based on data he collected, arising from my hypothesis and design of the study. I critically reviewed the paper.
Paper 8 was written by another of my registrars, Dr Kwang Lim, from data he collected, based on my hypothesis and design of the study, with Professor Wren recruiting half of the patients and two cardiology registrars, Drs Jepson and Roy performing the echocardiographs. We all critically reviewed the manuscript. Paper 9 was written by Anne-marie Boxall, a physiotherapist who worked for me, collected the data, based on my hypothesis and study design, and wrote up the paper. Allyn Sayers was a data manager employed by me. I reviewed the paper for critical intellectual input. Paper 10 and 11 were invited papers that I co-authored.
How this research relates to the central theme The orthogeriatric service formed the basis of my research work, in my attempt to discover if and how the service was improving the outcomes for patients. The service provided holistic care for older orthopaedic patients, by supplementing their orthopaedic care in hospital with comprehensive geriatric assessment starting in the Emergency Department and including geriatric medicine supervision of their medical issues on the ward, then early discharge so that post acute care was provided at home until the patients were fully rehabilitated. After this time we followed up the patients with an integrated program to prevent further fractures, including starting and supervising investigation and treatment of osteoporosis and an exercise program to improve balance and prevent falls.
MD Thesis Introduction 7
Thus, some of the papers relate to improving care for patients on the ward, eg 6 and 9, some relates to fall prevention eg 2 and 4, some to osteoporosis assessment and treatment, directly and indirectly eg 1, 3, 5, 7, 8. For example, in the 1990s one of the treatments we were using for osteoporosis was hormone replacement therapy, and we were able to partner with some colleagues in cardiology and gynaecology to investigate some novel insights into this treatment.
Papers 10 and 11 place my work within the overall context of community care for older people in Australia and demonstrate the impact and implications of my work.
The significance of the work Initially there was limited interest in the orthogeriatric program, mainly from government. I was invited to convene a panel sponsored by the Commonwealth Department of Health (DOH) to formulate guidelines for post acute care which were published in a small monograph by the
DOH.1 A survey conducted in 1992 found that about 3% of hospitals had orthogeriatric programs whereas by 2001 still only 4% of Australian hospitals had acquired such programs. 2
However, in 2008 the NSW Department of Health sponsored a program to establish orthogeriatric programs in all metropolitan hospitals.
Interest in these ideas started to increase when, in 1995, the Commonwealth DOH commenced the National Demonstration Hospitals Program (NDHP) which used a mentor model to encourage dissemination of effective health service innovations through the health system. The
Department selected Lead Hospitals who were funded to mentor a group of Collaborating
Hospitals to set up services similar to those running at the Lead Hospital. I wrote the applications and subsequently managed the Prince of Wales Hospital (POWH) involvement as
Lead Hospital in three out of four phases of the NDHP. The first phase 1995-97 was focussed on management of elective surgery and POWH was selected for its expertise in Discharge
MD Thesis Introduction 8
Planning and Post Discharge Services, based on the orthogeriatric service, as well as other programs which I had been instrumental in starting such as the post acute respiratory outreach service, general surgery program and Hospital in the Home (see below) Under the NDHP I acted as a consultant to 17 hospitals around Australia to help them set up their own version of the service I was running at Prince of Wales Hospital.
The NDHP also provided a national forum for the ideas I was researching of increasing care outside hospital by providing
1. Hospital in the Home, to replace the acute part of the admission, for example providing intravenous antibiotics or anticoagulation with low molecular weight heparin and warfarin
2. post acute care, to replace the rehabilitation part of the admission, eg after a fractured hip
3. chronic disease management, to prevent future admissions.
4. comprehensive geriatric assessment for older people in the Emergency Department
(ED) to allow better and more timely care and consideration of options other than admission to hospital, as well as improved post ED care
NDHP led to widespread uptake of these ideas at different levels of the health system, by individual hospitals, area health services and health departments. I cannot claim to be the only proponent of these ideas; however by rigorously testing these new methods of treatment, I was able to generate evidence that supported their uptake, which in at least some instances proved to be a “tipping point”.
The final report for NDHP I showed that across the whole program average LOS reduced by 6% and case rates (patients/bed/month) increased by 6.3%, despite average available beds decreasing by 3.0%, whereas unplanned readmissions decreased by 27%. The report estimated that the program generated gross savings of between $89.5-110M against the cost of the
MD Thesis Introduction 9
program which amounted to $11M. 3 The POWH consortium of Lead and 7 collaborating hospitals generated results which were better than this average, with total and elective surgical admissions both increasing by 8%, despite a 12.5% decrease in average available beds, indicating even greater efficiency, reflected in the case rate increasing by 18.9%.
The third phase of NDHP aimed at integration involving hospitals and the primary and community sectors working together to establish systems that provided a smooth transition across sector boundaries. Because our existing services already worked across these sectors, in a hospital outreach model, we were well placed to be involved.
When the fourth phase of NDHP, which only ran for 12 months during 2002-03, decided to target improved care of older patients in hospital, at my suggestion, we were equally able to step into a Lead Hospital role. By this time my Geriatrician colleagues called me Mr NDHP, and altogether POWH received just under $4M in NDHP funding. Although much of it had to be spent managing and running the project, including grants to the collaborating hospitals, the contribution to our research funds included about $1.5M.
NDHP also gave me a real life health service research “laboratory” to test the ideas and programs pioneered at POWH at other sites, to ensure that it was not simply a matter of local enthusiasm that the projects succeeded. It provided an in vivo demonstration that these systems were transportable. It also provided a wider audience, because each NDHP brought with it a range of conferences to which many hospitals not participating sent high-level staff members, and also hospitals collaborating with one lead hospital could glean ideas from other lead hospitals. This cross-fertilization provided benefits above and beyond those measured in the report, both to the hospitals taking up the systems and in other ways. These side benefits were highlighted to me when POWH underwent the triennial assessment by the Australian Council
MD Thesis Introduction 10
for Healthcare Standards to retain our hospital license, in 2004. The assessor who came to inspect PACS started the interview by saying that she had implemented DEED at her hospital, and it was fantastic.
MD Thesis Introduction 11
Table 2: The Hospitals I mentored and the projects they implemented during NDHP.
Phase 1 Theme: Elective Surgery Project
1995-97 Ballarat Base Hospital, Victoria General post acute care
Gippsland Hospital, Victoria Management of the episode of
care for high risk surgery
patients
Mackay Base Hospital, Queensland Post acute respiratory outreach
service
North West Hospital, Victoria General post acute care
Princess Alexandria Hospital, Brisbane, Orthogeriatric service
Queensland
Queen Elizabeth II Hospital, Brisbane, Orthogeriatric service
Queensland
Sir Charles Gairdner Hospital, Perth, WA Cardiothoracic surgery post
acute care
Phase 3 Theme: Integration across the hospital,
primary and community sectors
1999- Ipswich Hospital, Queensland General surgery program,
2000 Orthogeriatrics
Newcastle Mater Misericordiae Hospital, NSW Hospital in the Home
Alice Springs Hospital, Northern Territory Post acute care, with elements of
chronic care
North West Regional Hospital, Burnie, Hospital in the Home
MD Thesis Introduction 12
Tasmania
Rockhampton District Health Services, Discharge of Elderly from the
Queensland Emergency Department
Phase 4 Theme: Aged Care
2002-03 Austin and Repatriation Medical Centre, Orthogeriatric service
Melbourne, Victoria
Bairnsdale Regional Health Service, Victoria Discharge of Elderly from the
Emergency Department
Central Coast Health Service, NSW Geriatric Rehabilitation
Maitland Hospital, NSW Post Acute Respiratory Outreach
Toowoomba Health Service, Queensland Discharge of Elderly from the
Emergency Department
Background My interest in post acute care began in my first year of Advanced Training for Geriatric
Medicine in 1990 when I worked as a registrar at Prince of Wales Hospital. One of my duties was to work with the orthogeriatric team, the Post-acute Orthopaedic Rehabilitation Service
(PORS) which later changed its name to the Post Acute Care Services (PACS) when it became involved with multiple specialty units in the hospital under my management. PORS had been set up three months earlier by the Director of Geriatric Medicine, Dr John Ward, and the
Director of Orthopaedic Surgery, Professor Ron Huckstep, to improve the care of older patients admitted to the orthopaedic ward. At that time orthogeriatric programs were new to Australia, and therefore something of an unknown quantity.
MD Thesis Introduction 13
In June 1993 I was appointed to a Staff Specialist position at Prince Henry and Prince of Wales
Hospitals and a Lectureship at the University of New South Wales. As one of my duties I took over as director of PORS. At that time the initial proponents had moved on, the service was not viewed favourably by outsiders, the funding was due to run out in two weeks so it appeared that the service would imminently close. In an eye opening, for me, demonstration of the awesome power of inertia, we just kept going and three months after the end of the financial year we received official notification that the service was refunded. This allowed us to focus on longer- term survival. It was clear to me that the service was worthwhile but that if it was to be preserved, it was necessary to demonstrate that it was worthwhile. The most critical audience for health services is actually other clinicians, and therefore I felt it was necessary to carry out clinical trials to demonstrate whether or not the service was beneficial to patients. The first step was to document what the service did, and an article enunciating the philosophy and methods, or principles of post acute care, (paper 6) was published in the Australian Health Review.
There was very little medical literature about hospital substitution programs, and a great deal of scepticism, amongst health professionals and patients. The service was funded under a
Medicare Incentive Program called early discharge programs which funded three types of services, orthogeriatrics, paediatrics and obstetrics.
At that time, and still today to a lesser extent, any program with a stated aim of reducing length of stay (LOS) is viewed by clinicians with scepticism. Hospitals were then viewed as entirely benign, and totally beneficial, in their effects on patients. Any attempt to reduce length of stay was seen as a government initiative to save money, and clinicians stating that they supported shorter LOS were seen as, at best, deluded stooges of government. Thundering editorials were written attacking such ideas. 4 It was also clear that patients did not like this idea so baldly
MD Thesis Introduction 14
stated, many patients expressed a view that being in hospital was their entitlement, and the program’s initial self-description as an “early discharge program” was soon deleted from patient information brochures. However clinicians who observed at first hand the patient outcomes in the new program and had experience of the previous system were convinced that patients were doing better under the new program. This view was partially validated by the new experience of receiving frequent thank-you letters and encomiums from patients, to a much greater degree than had previously been experienced. Furthermore patients who were initially sceptical about going on the program needed no convincing if they happened to be later readmitted with another fracture or for a second joint replacement.
More solid validation of the view that the program was beneficial came from our own analysis of patient outcomes on the program which demonstrated health outcomes which matched the best in the world literature for older orthopaedic patients. However no analysis was done of prior health outcomes on the orthopaedic unit, and so we were unable to decisively demonstrate any improvement. Critics within our area health service were able to identify individual patients who had not done well, and frequently criticised the service on this anecdotal basis.
These criticisms came from both orthopaedic surgeons and geriatricians.
The outcomes that we did measure showed that there was a marked reduction in length of stay, eg. hip fracture length of stay reduced from 27.5 days in 1988 to 14 days in 1991 and this was not accompanied by an increase in re-admission rates. The six-month mortality rate for hip fracture patients was 15% against the published data which showed a range of 14-20% (see table)
MD Thesis Introduction 15
Table 1: Comparison with world literature 5,6,7,8,9,10,11
POWH 1991 World literature 1985-89
Length of stay (days) 14 3-44
Inpatient mortality (%) 3.5 1-11
6 month mortality (%) 15 14-20
Returning home (%) 44 34-77
At home at 6 months (%) 67 60-82
ATTITUDES TO OSTEOPOROSIS
Paper 7 was based on an idea I conceived, with the data collected by my Advanced Trainee at the time, Dr Nicholas Brennan who drafted the paper.
From the start of the program we sought to address long-term health issues that arose from the admission but had not been previously addressed, such as finding the reason for falling and treating it, as well as treating osteoporosis. During the first few years we found that public awareness of osteoporosis was low, there were few effective treatments available and many fracture sufferers were reluctant to take the available treatments. Common responses encountered from patients were either “I’m too old to worry about treatment” or “I’m not going to fall over again” therefore I do not need treatment. I designed a short educational intervention which was delivered on the ward and, we demonstrated in the Osteoporosis International paper that, it significantly increased the percentage of patients starting on treatment for osteoporosis.
Certainly, the passage of time with the release of more effective medications for osteoporosis, particularly the more effective Bisphosphonates, but then also the Selective Estrogen Receptor
Modulators, Parathyroid Hormone and Strontium have revolutionised for the better the
MD Thesis Introduction 16
treatment of osteoporosis, which is now standard. The attitudes to osteoporosis study demonstrated that you could quadruple the number of women going onto treatment for osteoporosis with a brief educational intervention. In the attitudes to osteoporosis paper we concluded by recommending that routine management of all older orthopaedic fracture patients should include counselling about osteoporosis. This is now routine policy for all osteoporosis organisations.
WEEKEND PHYSIOTHERAPY
One of the fascinating aspects of health service research is trying to work out how much of the package that goes into a new health service is essential, and how much is luxury that could, in a pinch, be discarded. On a laboratory bench it is easy to set up a range of experiments and compare different doses and different mixtures, but in the laboratory of the hospital ward that is almost impossible, almost. In 2001 I had the opportunity to design such a test of part of the package of our orthogeriatric service. A vitally important part of the package was early mobilisation, which was dependent on early stable fixation, resolution of some medical problems and plentiful physiotherapy services. We set up a trial to test if incrementally adding to the physiotherapy services by supplying a weekend physiotherapist would hasten and increase independence, facilitating earlier discharge. We decided to do this without making any other changes, but everyone was informed of the increment to services and the results of the mobilisation by the weekend physio was recorded in the notes. The 7 day a week physiotherapy service in a controlled before and after trial with 240 subjects, did not demonstrate an overall decrease in LOS. While time to independent transfers and mobility improved by half a day overall, only one subgroup, ankle fractures, showed a near significant reduction in LOS by 4 days, overall LOS decreased only by 0.2 days
BALANCE, FALLS AND FRACTURES
MD Thesis Introduction 17
As a result of my involvement with the Orthogeriatric program I have been fortunate in being able to explore in depth some particular aspects related to osteoporosis and falls in older patients with fractures.
An interest in the relationship between exercise and bone density and sensori-motor function as it relates to falls and fractures in the elderly led to my initiating two separate but related controlled studies of older patients and enlisting collaborators from Prince of Wales Hospital,
Drs Ward and Colagiuri and Mrs Colagiuri, and the University of New South Wales, Dr Lord, to carry them out. These studies were unfunded. I recruited the patients and controls for these studies and organised them to come in to the hospital to be studied by me and my co- investigators.
The first study was of a group of non-exercising women aged 57-75 years (mean 65) who volunteered for a one year exercise program which consisted of a twice weekly 60 minute session of weight-bearing low impact aerobic exercise with an emphasis on coordination and balance training. An element of strength and flexibility training was included. Patients were encouraged to ‘work out’ at least one other time per week. A control group was recruited, though not randomised. Both groups underwent a medical assessment and diet history at the start and dual photon absorptiometry bone density (DPA) study before and after the 12 months.
At the end of the 12 months they were also assessed for sensorimoter function including balance, reaction time and muscle strength. Interestingly the study found significant gains in bone density in the lumbar spine and greater trochanter of the femur, and significantly better quadriceps strength reaction time and sway on a compliant surface in the exercisers compared to the controls.
MD Thesis Introduction 18
The second study looked at older diabetic patients. Patients with diabetes are at greater risk of falls because of diabetic complications, which impinge directly on sensorimotor function including diabetic retinopathy and cataracts affecting visual acuity and peripheral neuropathy, and accelerated vascular disease affecting gait and balance. Older diabetics most commonly have type II, non-insulin dependent diabetes and tend to overweight, which is associated with protection of bone density. Thus although they may fall more frequently they do not have a higher rate of fractures. However obesity is itself a risk factor for more severe diabetes and vascular complications, so weight reduction is generally beneficial, but may have an adverse effect on bone density. I recruited two groups of elderly diabetic patients, one of whom consented to enter a 12 month exercise program the same as in the previous study and the other did not. The patients underwent DPA and sensorimotor testing before and after the 12 month study. The findings were a significant improvement in lumbar spine bone mineral density, weight, body mass index, Life Satisfaction Index-A in the exercisers compared to the controls.
Although the lack of randomisation in one sense detracts from the applicability of the result, these studies probably more closely mimic what happens in real life, in that many people simply cannot be persuaded to start exercising.
In the mid-1990s we found that caring for older patients with fractures was frequently disappointing because of the poor acceptability of anti-osteoporosis treatment amongst this group, frequently due to perceptions of therapeutic nihilism. Although the acceptability of such treatment has definitely improved over the years, the immediate post-fracture period is a
“window of opportunity” to introduce secondary prevention strategies. We tested the effect of a short educational session on these patients and found a significant increase in the willingness to take anti-osteoporotic medication amongst fracture patients when compared to joint replacement patients.
MD Thesis Introduction 19
Involvement with the orthogeriatric service led me to think more generally about the surrounding medical issues. In that section I have mentioned what I consider to be directly related research into falls and osteoporosis. But the thought processes were not stopped by the boundaries of what was directly relevant. So paper 8 describes a study into the non-osteoporotic side of one of the treatments for osteoporosis. At that time, in the mid 1990s, one of the most common treatments for osteoporosis was hormone replacement therapy (HRT). This led me to ponder on the benefits of HRT and to see whether we were not ideally placed to add to medical knowledge in this area. At that time when we explained the benefits, as they were understood, of HRT to patients we emphasised the cardiovascular benefits, but their mechanism was not clear. Although there was some evidence for a decrease in mortality due to the anti-osteoporotic effects, in the early to mid-1990s there was thought to be a 44% decrease in cardiovascular mortality based on epidemiological studies, which is much more significant.
We hypothesized that some of the purported beneficial effects of HRT may be due to myocardial remodeling because of known effects of oestrogen on smooth muscle. If this were so, it would not be something that could be detected in a short-term trial, because the effects may take years to show up. We performed a case control study of the effects of long term (>10 years) HRT on left ventricular (LV) mass, known to be one of the most important predictors of cardiovascular death. In this study we found a 20% decrease in LV posterior wall thickness and
LV mass, the first study to find this. This has important implications for the length of time needed to observe beneficial effects from HRT on cardiovascular mortality.
However, subsequent prospective RCTs with thousands of subjects found no benefit on mortality and then vastly increased mortality from HRT, which made this a research dead end. 12,13
MD Thesis Introduction 20
MD Thesis Introduction 21
2. Post Acute Respiratory Outreach Service
12. Brown A Caplan G. A post-acute respiratory outreach service. Australian
Journal of Advanced Nursing 1997; 14: 5-11. [Journal Impact Factor = 0.592;
Citations at 15/9/2009 = 2]
13. Boxall A-m Barclay L Caplan GA. Managing chronic obstructive pulmonary disease in the community: a randomised controlled trial of home based pulmonary rehabilitation for elderly, housebound patients. Journal of
Cardiopulmonary Rehabilitation 2005; 25: 378-385. [0.602; 15]
My role in this research Paper 12 was co-written by Ann Brown and myself describing the service. We reported result of a cohort study, using a simple before and after design, based on our joint hypothesis that such a service could reduce readmissions. Paper 13 reported our RCT which was based on my hypothesis and study design, but Anne-marie Boxall, a physiotherapist who worked for me, collected the data and wrote the paper, which she subsequently used as the basis of the thesis for her Masters of Public Health (Hons) degree.
How this research relates to the central theme A vital component of caring for older people at home instead of in hospital is improved management of their chronic diseases. Such programs help to prevent later admissions to hospital and shorten the duration of these admissions, as well as substituting at the point of admission by linking with our Hospital in the Home service to provide acute care at home as an alternate for hospitalization. Subsequently this has also been demonstrated in other disease groups, particularly patients with congestive cardiac failure.
MD Thesis Introduction 22
The significance of the work Our service, set up in 1993, was one the first community chronic disease management program in New South Wales (NSW), my home state. The increased interest that this and similar work around the world stimulated led to the funding by the NSW DOH of chronic disease programs across NSW. In 2001 the Chronic and Complex Care Implementation Group, of which I was a member, convened and funded by the NSW DOH, paid for every area health service in NSW to start chronic disease programs for Respiratory, Cardiac and Cancer patients.
Background In the early 1990s the idea of a randomised controlled trial (RCT) of a health service in
Australia was unusual. There was a circular argument that mitigated against vigorous analysis.
In order to ensure that the service actually worked, and to eliminate any “bugs”, one had to get the service up and running. However, once it was working satisfactorily and one could demonstrate in a series of patients that outcomes were satisfactory, it was then argued that it was unethical to run a RCT because that would mean depriving some patients of the current “gold standard” treatment. However, if no valid trial had been run, one could not actually say what was the gold standard. Many people also argued that a case series was sufficient evidence to justify changing health services, while reviewers such as Cochrane clearly argue that anything less than a RCT is invalid evidence. RCTs have many strengths, particularly to minimise biases in patient allocation. The prospective consumer of the evidence is also important, medical practitioners are more comfortable with RCTs whereas nursing and allied health professionals as a group are more accepting of case series as adequate evidence.
Because of these arguments we decided not to suspend the orthogeriatric service to conduct a
RCT, but to evaluate the benefits of home treatment in other areas.
MD Thesis Introduction 23
Even if you decide that an RCT is not possible, it is difficult to demonstrate that a service is worthwhile when it has been going for over three years, if you have not collected data before it started. Once a service is established it is ethically problematic to recruit a control group who must be denied an existing service. Therefore the best, and often the only, opportunity to perform a controlled evaluation is at the time of starting a new service. This brings different problems, particularly if an economic evaluation is included. A new team initiating a new service will not be performing at peak efficiency, as it will be operating a less than maximal throughput because it takes time to build up referrals. However, if you add-on a new service to an existing team, you achieve economies of scale, do not need to accrue the entire cost of the administrative infrastructure to the new service and can utilize services on an as-required basis, where team members work mainly on the existing workload, and on the new service only when a referral is received. This arrangement also has the advantage that it is a true experiment, because you do not know whether the new service will work. But unlike a laboratory experiment, there is only one opportunity to ‘get it right’. By careful planning, and building incrementally on progress already achieved, you hope not to get burned too badly.
There are specific difficulties in defining, developing, documenting and reproducing complex interventions that are subject to more variations than a pharmaceutical agent. This has led some to argue for a process to evaluate complex interventions. There is already a process for drug evaluation with 4 phases. Phase I evaluates the safety of a new compound, phase II looks to discover any benefit of the compound, phase III compares the new drug to placebo or control and phase IV is the post-marketing survey. Campbell et al advocate a four phase model for evaluating complex interventions, of which hospital in the home is specifically cited as an example. 14
MD Thesis Introduction 24
Campbell Model
Preclinical Theory Explore relevant theory to ensure best choice of intervention
and hypothesis and to predict major confounders and
strategic design issues
Phase I Modelling Identify the components of the intervention and the
underlying mechanisms by which they will influence
outcomes to provide evidence that you can predict how they
relate to and interact with each other.
Phase II Exploratory Trial Describe the constant and variable components of a
replicable intervention and a feasible protocol for comparing
the intervention with an appropriate alternative
Phase III Definitive Compare a fully defined intervention with an appropriate
randomised alternative using a protocol that is theoretically defensible,
controlled trial reproducible, and adequately controlled in a study with
appropriate statistical power.
Phase IV Long term Determine whether others can reliably replicate your
implementation intervention and results in uncontrolled settings over the
long term.
The Campbell model presents one paradigm for evaluating complex health interventions such as hospital in the home, but it is not the only one. I would argue that because of the context in which health services exist and their testing takes place, it is more difficult for the credibility of the service, and the service provider, to establish a service then withdraw it, then restart it.
Especially where one depends on multiple sources of referrals. Providers do not want to refer patients to a service which is temporary. The testing of pharmaceutical agents largely takes
MD Thesis Introduction 25
place outside the health system, till phase III at least. Testing of health services perforce has to be within the health system.
A major problem with multiphase testing is that funding is generally inadequate for rigorous evaluation of health services. A number of studies I have performed have, in effect, been partially subsidised by our general budget. This subsidy was included in the economic analyses that we performed, but without careful control of the budget and a strong commitment to research, the study would not have been possible. To give you an idea of relative costs, the
Hospital in the Home study received $240,000 which equated to $2,400 per subject. I was informed that, at that time, the average cost of doing a drug trial in Australia was $10,000 per subject, and in the US was much more than that. The DEED II study that we carried out received funding of just over $1000 per subject.
So it was decided to gradually expand the services offered to different departments of the hospital and use the opportunity to evaluate the new services, which are in many ways variations on a theme. The first example of this was in 1993, after discussions with a
Respiratory Physician and a Community Geriatrician, the problem of elderly patients with
Chronic Obstructive Pulmonary Disease (COPD) who had recurrent admissions to hospital was raised. This was before the idea of chronic disease management or self-management became so popular, but the concept that was arrived at was basically a form of this. This service was started without any extra funding, but by reorganising our existing workload to free up one nurse, who went overnight from being an orthopaedic nurse into an intensive training program to be a respiratory nurse. The nurse already had the advantage of knowing how to work across the hospital community divide with elderly patients with multiple comorbidities, but needed some additional technical knowledge.
MD Thesis Introduction 26
The two papers in this area demonstrate how my research methodology became more sophisticated. The first one was a case series using historical controls and the second was a randomized controlled trial. The second paper studied housebound patients with chronic obstructive pulmonary disease and shows how one can work with the most frail patients at home. To be suitable for this trial subjects had to be housebound because of their COPD. There was a high level of comorbidity and three subjects died during the trial, and out of 60 initial subjects, only 46 completed the trial. This was also the first study of home pulmonary rehabilitation for truly housebound subjects that included subjects with comorbidity, but demonstrated again that a ‘take-all-comers’ approach is better than a methodology involving a long list of exclusions.
Key Findings
The pilot controlled trial in 1993 found that the readmission rate decreased from 15% to 7.7%, so the Respiratory Outreach Service was commenced in October 1993 as a clinical strategy in respiratory medicine. This initial evaluation used retrospective data on historical controls to assess the readmission rate, but it demonstrated that slightly more rigorous analysis was achievable, that an impact could be made and measured on health outcomes such as readmission rates, suggesting a way forward using more rigorous analysis.
The pulmonary rehabilitation trial found that the intervention led to improvements in exercise tolerance, perceived dyspnoea and quality of life. At six month follow up there was also significantly shorter LOS during readmission to hospital with COPD exacerbations.
MD Thesis Introduction 27
3. Reengineering of elective surgery
14. Caplan GA Brown A Crowe PJ Yap S-J Noble S. Reengineering the elective surgical service of a tertiary hospital: a historical controlled trial.
Medical Journal of Australia 1998; 169: 247-251. [Journal Impact Factor =
3.320; Citations at 15/9/2009 = 13]
15. Caplan GA Board N Paten A Tazelaar-Molinia J Crowe PJ Yap S-J
Brown A. The cost to the community of decreasing lengths of stay. Australian and New Zealand Journal of Surgery 1999; 69: 433-7. [0.783; 16]
16. Board N Caplan G. Implications of decreasing surgical length of stay,
Australian Health Review 2000; 23(2): 71-85. [0.807; 5]
17. Board N Caplan GA. Use of pathology services in re-engineered clinical pathways. Journal of Quality in Clinical Practice 2000; 20: 24-9. [ -;-]
18. Henderson A, Caplan GA, Daniel A. Patient satisfaction: the Australian patient perspective. Australian Health Review 2004; 27: 73-83. [ 0.476;-]
NB the Journal of Quality in Clinical Practice has ceased publication, therefore no impact factor is obtainable.
My role in this research The re-engineering of elective surgery research was based on a collaboration between my service, the surgical and anaesthetics departments. I chaired the steering committee, received the funding for the research component, designed the research based on my hypothesis, and employed the data collectors. For papers 14 and 15 I analysed and wrote up the data. Papers 16 and 17 were based on additional data from the same study, which was analysed and written up
MD Thesis Introduction 28
by Neville Board. Paper 18 was based on a hypothesis by Amanda Henderson, refined with my input, and she collected the data and wrote up the paper, while I provided critical intellectual input. This paper was submitted as part of her PhD thesis. My co-authors on these studies included Ann Brown, who was the Nurse Manager for PACS, Phil Crowe, a surgeon, Sue-Jen
Yap, an anaesthetist, Shaune Noble, a health administrator, Neville Board, a data manager I employed, Anne Paten and Jodie Tazelaar-Molinia, two nurses who worked for me, all from
Prince of Wales, and Amanda Henderson and Ann Daniel from the University of New South
Wales.
In 1994 I received funding from the Commonwealth Department of Human Services and Health
Hospital Access Program in collaboration with the Health Development Services Unit to look at the question of elective surgical services. Because of my involvement with orthogeriatrics I had experience with post-op care of elective and emergency surgical patients. So attention was turned to general surgical patients. The hospital agreed to move to the ‘perioperative model’ whereby patients admission is coordinated by a perioperative unit which sends out, receives and reviews patients’ self-reported health questionnaires, and arranges preadmission assessment, if indicated. Patients come to the perioperative unit for a day of surgery admission (DOSA).
After surgery, day-only patients return to the perioperative unit and others go the surgical ward.
The surgeons distribute patient information specific for each operation, and nurses reinforce patients’ knowledge. Clinical pathways are followed, providing a diagnosis specific plan for the episode of care and the role of each team member in the multidisciplinary team. Post acute care continues at home after discharge, if required.
MD Thesis Introduction 29
How this research relates to the central theme This research examined the increasing shift of care for surgical patients out of hospital. By providing preoperative assessment and post acute care at home, many surgical patients need only be in hospital for the operative day.
The significance of the work The work, by demonstrating a decrease in surgical wound infections associated with shorter length of stay, led to the decision in 1999 by the NSW DOH through the Acute Care
Implementation Group to mandate day of surgery admission (DOSA) as the standard of care for
NSW hospitals, setting targets for all hospitals to achieve. That this study was one of the driving forces behind this change was demonstrated by the DOH organized publicity campaign around the changes, with a feature in the Sydney Morning Herald on March 18, 1999 six months after the study was published, which prominently featured our results. The study was also cited on the DOH website supporting these changes. 15 Within a short time most hospitals were achieving DOSA rates of over 80%. Our study was definitely not the first to examine DOSA and early discharge, but we were the first to demonstrate a decrease in complication rates thereby.
One of the unexpected consequences of this study was the interest by the general media in anything involving surgery and waiting lists. As well as coverage in the Sydney Morning
Herald and the Age at the time of publication, I was interviewed by five different radio networks, including the BBC. The story mysteriously also appealed to the World Socialist Web
Site. 16 The popular media reaction to this publication compared with my studies of medical patients revealed to me that there was deemed to be much greater newsworthiness associated with the care of surgical patients than medical ones.
MD Thesis Introduction 30
Background Surgery and surgical waiting lists were, at that time, the political and media football that got kicked around a lot, especially at election time. A lot of surgeons and anaesthetists were wary of any idea that came from the government, or that appeared to be designed to get the government off the hook. At the same time, they were keen on any changes that made it easier to get elective surgery patients into hospital for surgery. So fundamentally, everyone’s goals coincided.
Establishing this model required close cooperation from the anaesthetic and surgical departments. These are both large departments and while not every member of both departments was totally in favour of moving to this model, clinicians in leadership positions were supportive. Often this meant reaching out to them. Instead of expecting busy clinicians to come to meetings, and if they would not the project lapsed, I got changed into surgical scrubs and met them in the operating theatre tea room. A lot of difficulties were overcome in this way.
This model had been refined over decades, the first DOSA being reported in the early 1960s and had clearly delivered shorter lengths of stay and therefore administrative efficiencies, but I wanted to study the effects on health outcomes, patient satisfaction the impact on unpaid carers, as well as community services. There were no data pertaining to these aspects.
Some years later, in Patient satisfaction: the Australian patient perspective (paper 18) I was able to extend these findings in collaboration with researchers in the School of Sociology to try to unravel the elements of patient satisfaction. To capture the patients’ viewpoint, this study consisted of repeated interviews with patients before, during and after their hospitalization for general surgery, using a phenomenological approach to understand the patients’ construct of
‘satisfaction’.
MD Thesis Introduction 31
Key Findings
This was a breakthrough study because it was the first prospective controlled intervention trial to demonstrate that keeping people out of hospital decreases complications. Many previous observational studies had shown that patients who have shorter LOS have fewer complications, but then it was argued that patients who stay longer are sicker and older, and therefore are prone to more complications. We found that wound infections decreased from 16.5% to 5.0%
(p=0.0075), probably mostly due to lack of exposure to the hospital microbial soup before surgery. We also showed that there was no inconvenience placed on patients or, where applicable, their carers, (no extra time off work was required) and that patient satisfaction was higher in the new pathway, 93% wanted their surgery done the same way in the new pathway compared to 83% in the old system (p=0.037).
The accompanying editorial in the Medical Journal of Australia described the article as “a major achievement”. 17 Subsequent analyses confirmed that the new system was considerably cheaper on a per patient basis, although the shorter length of stay actually permitted increased turnover in the hospital, so there may not have been an overall saving, except in building additional wards or hospitals and staffing them to meet the demand. We also demonstrated that using the clinical pathway reduced overall pathology and radiology use.
The Patient Satisfaction study identified 16 themes that are important for patients. It identified important themes that are not covered by standard patient satisfaction indices. Since the new themes are ones that cover the areas that generate most complaints, after comparison to data arising from Health Care Complaints Commission data, it will be important to take this work forward.
MD Thesis Introduction 32
MD Thesis Introduction 33
4. Hospital in the Home
19. Caplan GA Ward JA Brennan N Board N Coconis J Brown A. Hospital in the Home: a randomised controlled trial. Medical Journal of Australia 1999; 170:
156-160. [Journal Impact Factor = 3.320; Citations at 15/9/2009 = 74]
20. Board N Brennan N Caplan GA. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Australian and New Zealand Journal of Public Health 2000; 24(3):305-
311. [1.556; 25]
21. Caplan GA, Coconis J, Woods J. Effect of Hospital in the Home treatment on physical and cognitive function: a randomised controlled trial.
Journal of Gerontology: Medical Sciences 2005; 60: 1035-1038. [3.500; 16]
22. Caplan GA, Coconis J, Sayers A, Board N. A randomised controlled trial of Rehabilitation of Elderly and Care at Home Or Usual Treatment (The REACH
OUT Trial). Age and Ageing 2006; 35: 60-65. [3.052; 15]
23. Caplan GA. Hospital in the home: a concept under question. (editorial).
Medical Journal of Australia 2006;184: 599-600. [3.320; 6]
24. Caplan GA. Does Hospital in the Home treatment prevent delirium? Aging
Health 2008; 4(1): 69-74. [0.068; 0]
My role in this research These papers report on two separate randomized controlled trials. For both the Hospital in the
Home (HITH) and REACH OUT study I was one of two chief investigators who obtained the
MD Thesis Introduction 34
funding, but came up with the idea of conducting a randomized controlled trial for these studies, designed the research methodologies, and conceived the idea of focusing on adverse events and side effects of hospitalization for older patients, as a way to differentiate care at home from care in hospital. I performed the analysis and wrote papers 19, 21, 22 and 23. Dr Ward was the other chief investigator on the HITH study, Dr Brennan was the Advanced Trainee working under my supervision, Neville Board the data manager I employed also performed the analysis and wrote paper 20, Jan Coconis was a nurse I employed, Ann Brown was the initial Nurse
Manager of PACS and Jan Woods was the next Nurse Manager. I was the sole chief investigator on the REACH OUT trial. Papers 24 and 25 were an editorial and a review that I was invited to write to synthesize major aspects of the HITH work, along with a number of other trials around the world which successfully (in three out of four cases) replicated my finding of decreased delirium associated with HITH treatment.
How this research relates to the central theme This area of research includes two separate randomized controlled trials which have directly compared care at home with care in hospital. In the first trial patients were randomized in the
ED, and those allocated to home treatment were taken home within 24 hours of presentation, on average after 8 hours. In the second trial, older patients in hospital who required rehabilitation were randomized to home versus hospital rehabilitation after seven days in hospital.
The significance of the work Following the release of my results HITH services began to spread across NSW, slowly at first, but there now exists a network of HITH services covering almost the entire metropolitan area and other major centres. NSW Health has adopted the title of Community Acute/Post Acute
Care (CAPAC) and a DOH committee which I co-chair provides central coordination for HITH and post acute care services. The DOH encourages hospitals and area health services to use the
MD Thesis Introduction 35
Sustainable Access Funding, the yearly increases in funding, to start or expand their CAPAC services.
The 1999 HITH paper was the subject of an editorial in the MJA, was summarized in the
American College of Physicians ACP Journal Club and cited in five Cochrane reviews. 18,19,20,21,22,23,24 I won a NSW Health Baxter Better Health Good Health Care Award for
Innovation in 1999, the inaugural year of the awards, and was also a finalist in the Quality
Health Care category. A number of studies were set up around the world in an attempt to test our findings, and three out of four successfully replicated our findings, as can be seen in the review in paper 24.
The REACH OUT paper was also the subject of an editorial in the MJA, although it was published in Age and Ageing, which I was invited to write. REACH OUT was a finalist in the
2003 NSW Health Baxter Better Health Good Health Care Awards.
In 2007 I founded the Hospital in the Home Society of Australasia, which now has almost 200 members, holds an annual scientific meeting and has started publishing a scholarly journal as well as a newsletter. In 2009, following submissions from the Society, HITH was favourably mentioned in the Garling Report into Acute hospital services in NSW and in the National Health and Hospitals Reform Commission report. Indeed the fourth recommendation of the Garling report was for an increase in HITH services.
Background I had been exploring and broadening the concept of post acute care by looking after sicker and sicker patients at home until it became clear where to go next. The concept of home treatment of acute illness had been re-popularised in the United States in the late 70’s early 80’s with an
MD Thesis Introduction 36
enormous acceleration in the 90’s, driven by the insurance companies. However, in truth, it was merely a return to where it all began. Historically all health care had occurred in the home, particularly for the wealthy who could afford to pay for doctors to come to them. Hospitals were founded as refuges for the poor and dying, so that people were truly afraid to go to hospital. Advances in antisepsis, medicine and surgical techniques changed the image of hospitals only from the 1920s and 1930s.
There were many reasons for the increased provision of hospital care at home according to a
Kings Fund Report 25
1. Increasing proportion of elderly and very elderly people
2. The cost of maintaining patients in sophisticated high technology hospitals
3. The high cost of constructing new hospitals
4. Cost constraints in the health care sector and the search for cost-effective alternatives to acute hospital care
5. Problems of hospital-acquired infection, excessive bed rest and psychological trauma associated with hospital stays
6. Evidence of more rapid rehabilitation for certain conditions
7. Unsuitability of acute hospitals for certain kinds of care
8. Better understanding of the possibilities of early discharge combined with intensive nursing care at home
9. Decrease emphasis on institutional care in all sectors
10. Improved standards in the home, meaning improvements in hygiene, wider availability of electricity, telephones and refrigeration.
11. Developments in home-based high technology care, improved equipment such as intravenous fluid pumps, ventilatory devices for assisted respiration and home dialysis machines.
MD Thesis Introduction 37
12. The importance of providing consumer choice, where possible
13. Changes in federal policy (US)
Although the evidence provided to support many of these claims was slight in terms of our current hierarchy of evidence-based medicine, particularly numbers 4-7, some others such as 1-
3 are generally accepted, while the basis for some such as 7 may have been considered contentious and also number 12, despite the comments of the Chairperson of the UK Patients’
Association:
No one who has been involved in the patient representation side of health care over the last 25 years or so could possibly fail to be anything but excited and delighted at the prospect of greater emphasis on hospital care at home. 26
In 1995 John Ward and I received a grant to set up a Hospital in the Home (HITH) service.
Rather than merely set up a new arm of our service, I decided to mount a randomised, controlled trial although the grant was insufficient for this purpose. There were a number of reasons for an
RCT. I had been pushing the team towards increasingly rigorous evaluation techniques and they were now ready for an RCT. Secondly, HITH offered the perfect opportunity. At that time there had been no true RCTs of HITH published comparing complete admission substitution, at home, with in-hospital care. Thirdly, the increasing flow of evidence about complications and adverse events associated with hospitalisation, and the claims of improved outcomes with HITH from America without any good evidence to support them, virtually demanded an RCT.
Another important reason for an RCT was to meet head-on the antipathy that existed towards
HITH in Australia. This had been expounded most clearly in the medical newspapers, for example an article entitled “Legal quandary over hospital in the home” which essentially
MD Thesis Introduction 38
attempted to scare General Practitioners (GPs) away from HITH for fear of medico-legal problems, saying that GPs need to be protected from HITH. 27 In a debate in the same paper, the negative case stated “the overriding factor driving their [patients] exclusion from hospital (or early discharge) is that related to the need to clear hospital waiting lists and to contain costs.” 28
A later article was even less restrained, starting with the sentence “The RACGP has bucketed a hospital-in-the-home program, saying it puts more pressure on overworked GPs and could lead to patients being put in permanent nursing care.” 29 While one could perhaps understand the sensationalism of the non-peer reviewed sector of medical publishing, this type of exaggeration in the absence of evidence also crept into the normally more circumspect corridors of scientific medical journals. An editorial in the official medical journal of the Royal Australasian College of Physicians written by three eminent professors of medicine baldly stated without references that “HITH delivers worse care at greater cost”! 30 It is difficult to defend against barbs thrown from the heights of the medical ramparts without solid evidence.
Perhaps it would have been more sensible to give up at that point. But I pushed on, recruiting two nurses to run the HITH service, one from the hospital and one from the community health service. Interestingly we found it much easier to recruit nurses than other areas of the hospital.
There were a number of reasons for this. Nurses were given a lot more autonomy in PACS than on the wards. There was no night shift, though we did institute overnight on call with HITH, although it is extremely rare for nurses to be called out. Finally we worked as a true multidisciplinary team, at times becoming interdisciplinary where different members of the team could take over others’ roles, for example nurses mobilising patients, rather than only physiotherapists doing this. Team members’ opinions are listened to and respected, but they also carry more responsibility, and see patients alone without colleagues to easily confer with.
We have found that this responsibility generally requires a nurse with at least three years
MD Thesis Introduction 39
postgraduate experience. Recruiting nurses from these two sectors brought the necessary combination of skills to manage acute patients at home.
The first phase consisted of developing protocols for treating patients at home, for example administration of intravenous antibiotics and blood transfusions and management of anaphylaxis. Hospital protocols needed major modifications to cope with the exigencies of home treatment.
One of the important factors permitting development of HITH was the synthesis of antibiotics with longer half-lives which could be given once a day, such as the third generation cephalosporin ceftriaxone, the realization that other antibiotics formerly given twice or three times a day were equally effective once a day in many patients, such as gentamicin and vancomycin, and the combination of probenecid with cefazolin enabling daily administration.
These antibiotics allowed treatment of most common infections to be done via daily nursing visits. Subsequently the production of relatively low cost infusors by Baxter allowed virtually all antibiotics to be administered via daily visits when a new infusor is attached to a centrally placed cannula.
I was keen to extend the previous work into health outcomes with surgical patients by looking at a broad range of hospital complications. The methodology of the Quality in Australian Health
Care Study (QAHCS) 31 was used, indeed employing two of their assessors to perform the analysis which looks for Adverse Events which result in death, permanent disability or significantly increased length of stay. This examination was extending by our own chart review to look for geriatric complications. We know that older people are prone to a range of hospital related complications which although often associated with permanent disability, particularly cognitive impairment, these resultant changes often go undetected, especially to hospital staff.
MD Thesis Introduction 40
Therefore we extended the QAHCS methodology and performed our own review for geriatric complications. As it turned out, we found that on almost all complications the advantage favoured HITH treatment, and in none did it favour in-hospital treatment. This was conceptually most significant for the lower incidence of acute confusion (delirium) seen with
HITH treatment. Although it had been previously recognized that hospitalization may induce delirium, the confounding factors of age and medical illness made it very difficult for most clinicians to accept. Delirium is particularly important because it is a marker for a range of poor outcomes, death, increased cognitive and physical disability and placement in residential aged care.
Subsequently three studies have confirmed a lower incidence of delirium with decreased stay in hospital, my own REACH OUT study cited above and two overseas studies. 32,33 I was invited to write about this phenomenon in an editorial in the Medical Journal of Australia in 2006.
REACH OUT
The REACH OUT study (Rehabilitation of the Elderly And Care at Home Or Usual Treatment) was an attempt to replicate what should have been done when PORS started. It was a randomized controlled trial of post acute care, focusing on rehabilitation, at home versus in hospital. Because the orthogeriatric service had been running for over 10 years when we started
REACH OUT, I decided to focus on a different group of patients, and in many ways a more challenging group of patients. REACH OUT enrolled only the frail older patients admitted to
Geriatric Medicine or other specialities and then referred to Geriatric Rehabilitation. The average age of patients enrolled was 84 years and over 20% were suffering from dementia.
Nevertheless, the trial was a great success, because it clearly documented what we had suspected from the start of our post acute journey, and gave RCT verification of the decrease in delirium.
MD Thesis Introduction 41
Key Findings
The 1999 MJA HITH paper was the first prospective randomized controlled trial to demonstrate that keeping people out of hospital improved health outcomes, by prevented a range of complications. This included a relative 25% decrease in Adverse Events as defined by the
Quality in Australian Health Care Study, although not statistically significant, and an absolute
20% decrease in confusion (delirium) (p=0.0005). There was also a 20% absolute decrease in bowel complications (p=0.0003) and a 14% absolute decrease in urinary tract complications
(p=0.01). Patients and carers were significantly happier with treatment at home, and GPs were equally satisfied with the HITH patients care compared to the in-hospital patients, contrary to the alarmist headlines cited above. Overall the cost with HITH was less than half the cost of in- hospital treatment. Detailed analysis of cognitive and physical functional outcomes showed that
HITH patients also had better functional outcomes than hospital treated patients.
The REACH OUT study replicated the finding of a decreased incidence of delirium, but only during the rehabilitation, or post acute, phase, when the intervention group were being treated at home. During the initial acute phase, when both groups were in hospital, there was no difference in the incidence of delirium. This study also demonstrated clearly that patients rehabilitate much faster at home. The rehabilitation phase was 7.18 days shorter in the home rehab group, whereas the acute phase was 1.6 days longer so overall LOS was 5 days less. But during the shorter rehabilitation phase patients attained the same functional level measured by the Functional Independence Measure. Again patients were more satisfied with treatment at home and the cost was significantly lower.
MD Thesis Introduction 42
5. Advance Care Planning
25. Caplan GA, Meller A, Chan S, Squires B, Willett W. Advance Care
Planning and Hospital in the Nursing Home. Age and Ageing 2006; 35: 581-5.
[3.052; 6]
26. Meller AE Caplan GA. Let someone else decide? Development of an advance care planning service for nursing home residents with advanced dementia. Dementia 2009; 8(3): 391-406. [0.066; 0]
My role in this research I received the funding for the Advance Care Planning service, designed the service and the study based on my hypothesis, performed the analysis and wrote paper 25. I recruited Anne
Meller to work on the project, Stella Chan assisted with data collection, Barbara Squires and
Wendy Willett sat on the management committee and assisted with critical intellectual input and review of the manuscript. Paper 26 was written by Anne Meller, with my critical intellectual input, describing the service that I had designed.
Initially the funding came with a condition that we not conduct a “study”, however, I took this to mean that we could not conduct a randomized controlled trial and so we evaluated the service through a controlled, but non-randomised, evaluation.
How this research relates to the central theme This research shows how indirect approaches can also be extremely effective in enabling treatment of patients in alternative ways to the standard in-hospital care. By advance care planning, ie educating carers and persons responsible for nursing home residents about the hazards of hospitalization and the nature of end-stage dementia, we obtained their agreement to
MD Thesis Introduction 43
pursue care in the nursing home rather than admission to hospital in the event of an acute deterioration. Our study found that this reduced hospital bed-day usage by nursing home residents by 10,000 bed-days per year, and at the same time mortality in nursing home residents decreased by 10%, compared to the control group.
The significance of the work Paper 25 was the subject of an editorial when it was published in Age and Ageing,34 and was a finalist in the 2004 NSW Health Baxter Awards. Within a few months of publication the NSW
DOH Advance Directives Working Party, which I had been invited to join, obtained funding to replicate the scheme in every area health service in NSW. There was also considerable interest from other states of Australia and overseas. For example, I was invited to act as a consultant to the Royal College of Physicians London and British Geriatric Society for the development of guidelines on Advance Care Directives in 2008, and invited to collaborate with other investigators in Australia and overseas on this topic.
Background From the inception of our HITH program we had treated nursing homes (NHs) residents in the nursing home. Some of these were referred from the ED but we also accept referrals direct from
GPs. In these cases a doctor and a nurse from HITH goes to the NH to assess the patient.
However we found that very few patients were directly referred by GPs because often the route to ED was via the evening locum service when the GP was unable to come out to see a resident quickly. Part of the problem was also that NH residents did not have any recorded plan about where and how they wanted or, indeed, if they wanted to be treated if they got sick. Surveys show that 80% of people are in NHs with end-stage dementia and the others have different end- stage diseases. Nursing homes actually deliver more palliative care than hospices, but usually no discussion goes on about end of life care. In 2001 I received funding to set up a chronic
MD Thesis Introduction 44
disease program in our local nursing homes, and we chose to focus on advance care planning.
The aim was never to deny residents access to hospital, but to help them and their families make an informed choice about treatment and its location.
A large part of the problem relates to the fact that hospitals are a dangerous place for older people, particularly frail older people, and NH residents are the frailest older people in our community. We knew anecdotally that all NH Directors of Nursing complain that when they send residents to hospital, if they return, they return in a worse state that when they left. The
New York Times described hospitals as places where NH residents receive futile, but “grueling procedures.” 35 Conversely a number of studies suggested that NH residents treated in the NH did better than those treated in hospital. So we employed one nurse to work across all 21 NHs in our local area to help them set up systems so that residents and their families could plan if and where to be treated, including the option of HITH treatment in the NH. The aim was for residents or their relatives to write an Advance Care Plan.
The Hospital in the Nursing Home/Advance Care Planning study found that although most people do not want to sign plans, perhaps fearing that this will limit their options, just talking about the issues resulted in a massive culture change. We used the NHs around another nearby hospital as a control group and found that by encouraging people to have treatment in the NH we reduced mortality by 10% compared to the control group, there was anecdotal evidence of increased carer and resident satisfaction, and there was a saving of 10,000 hospital bed days per year, over 27 beds every day of the year. This scheme paid for itself 10 times over.
MD Thesis Introduction 45
6. Discharge of Elderly from the Emergency Department (DEED)
27. Caplan GA, Brown A, Croker WD, Doolan J. Risk factors for admission after Discharge of the Elderly from the Emergency Department - The DEED
Study. Age and Ageing 1998; 27:697-702. [Journal Impact Factor = 3.052;
Citations at 15/9/2009 = 39]
28. Caplan GA, Croker WD, Brown A. Recognition of deficits of physical and cognitive function in the elderly by medical staff in the emergency department.
Emergency Medicine 1998; 10: 19-24. [0.375; 3]
29. Caplan GA, Williams A, Daly B, Abraham K. A randomised controlled trial of comprehensive geriatric assessment and follow up after discharge of elderly from the Emergency Department - The DEED II study. Journal of the American
Geriatrics Society 2004; 52: 1417-1423. [3.805; 65]
30. Wong DD, Wong RPC, Caplan GA. Self Rated Health in the unwell elderly presenting to the Emergency Department. Emergency Medicine
Australia 2007; 19: 196-202. [1.513; 3]
My role in this research I was the chief investigator who obtained two grants for the body of work underlying these papers. I generated the research hypotheses, designed the experiments and employed researchers to collect the data. I performed the analysis and wrote papers 27-29. Paper 30 was written by
Dr DD Wong under my supervision based on my hypothesis and using my data, previously collected, and the analysis was performed by the two Drs Wong.
MD Thesis Introduction 46
How this research relates to the central theme This research arose from the observation that older people (aged >75 years) who come to the
ED but are sent home have a much higher rate of subsequent admission than younger people.
After initially showing that the subgroup of patients who most commonly suffered these readmissions were those with deficits of cognitive or activities of daily living function, in paper
27, I proved that these were often not assessed in the ED, in paper 28. I then demonstrated, in paper 29, that comprehensive geriatric assessment of people over 75 in the ED with follow up intervention at home was able to reduce that rate of subsequent admission, thus providing yet another alternative to standard in-hospital care. This demonstrated the value of comprehensive geriatric assessment for a population at high risk of deteriorating health, but also pointed to the extra advantage that with more rapid geriatric assessment in ED, many people could be sent home rather than admitted.
The significance of the work After the interest generated by my work, in 2002 the NSW DOH funded Aged care Service
Emergency Teams (ASETs) in every major and many middle sized hospitals in NSW. These teams were constituted to perform comprehensive geriatric assessment in the ED to assist with discharge of elderly from the ED as well as ensure more efficient care of patients who required admission. Interestingly, the immediate trigger for this program was the need to respond to a perceived (by the media) meningococcal outbreak. The number of cases of meningococcal sepsis was not significantly greater than the long-term average, but there was a perception in the media that old people were clogging up the ED preventing unfortunate young people with meningococcaemia from being adequately treated, so the government had to act. Having a solution to pull off the shelf proved a winner. The ASET program was gratefully accepted by all funded hospitals and has proved to be a great success, and has attracted increasing funding over the years so that coverage in ED has gone from office hours five days per week to 12 hours per day and every days of the week. ASET programs have been set up all over NSW.
MD Thesis Introduction 47
Background In 1994 Ann Brown, the PACS Nurse Manager, and I began a systematic search, examining the care of older patients around the hospital to discover what would be the best area to extend the service into. Naturally we found older patients in large numbers in all areas of the hospital, and most of them were admitted via the Emergency Department (ED), and we discovered that the highest number of complaints received by the hospital actually arouse from the care of elderly patients in ED.
We were already on good terms with the ED staff. PACS had been seeing orthopaedic patients in the ED since it started. Some of these patients were admitted to the hospital but needed preoperative assessment and the commencement of discharge planning. Others, with orthopaedic problems that did not require surgery, were taken straight home by PACS instead of being admitted to hospital. These included Colles fractures, acute back pain, some fibula fractures that disabled the patient to the extent that they required immediate assistance with activities of daily living (ADL). Previously arrangement of these services took approximately three days, at a minimum. But PACS could introduce these services immediately, and add rehabilitation on top, so the patient could be taken home from the ED rather than admitted to lie in a bed waiting for the services to be harnessed. The number of ‘hospitalizations prevented’ was 17 in 1990 and 56 in 1991, as compared to those who came into hospital being 328 in 1990 and 405 in1991. 36
I did a literature review into how best to address the problems of the elderly in the ED. There is plentiful literature. Elderly patients more frequently attend the ED, are sicker when they arrive, have more tests, are diagnosed with more problems, and are more frequently admitted to
MD Thesis Introduction 48
hospital compared to younger patients. Once patients require admission, what else could you do?
Not all elderly patients presenting to ED are admitted, many are assessed, treated and go home.
But three studies in England, Australia and the United States that followed up patients aged 75 and over sent home (discharged) from the ED found that a significant proportion of them will subsequently by admitted to hospital or die, about 20% by one month. We called this group
Discharged Elderly from the ED (DEED). By comparison the percentage admitted to hospital within one month for patients aged 65 and younger is zero. Therefore being sent home from the
ED is a sentinel event for older patients, and a good time to intervene in this high risk population. However it was unclear whether one should intervene in all older patients sent home, or target a smaller group with a more intensive intervention. There were no data to suggest which patients one should target.
At that point I was fortunate enough to receive a grant from the Commonwealth Department of
Human Services and Health, National Hospital Quality Management Program which funded the
DEED I study which enrolled 468 patients aged 75 and over discharged from the ED. All subjects were followed up for one month to determine their outcome.
In 1995 funding was received for a follow-up study to address the problems found. A major randomized controlled trial with over 700 subjects, all Discharged Elderly from the ED
(DEED). The intervention group received immediate CGA. This was and remains the largest intervention study conducted in emergency geriatric medicine, and the largest RCT in geriatric medicine in Australia.
MD Thesis Introduction 49
Key Findings
In the DEED I study altogether 17.1% of subjects were admitted or died within one month. One might expect some medical diagnoses to be important in determining risk of subsequent admission, but they were not and actually dependence in ADL and instrumental ADL, deficits in cognitive function or receiving assistance at home such as from a community nurse, or meals on wheels were found to be significantly associated with subsequent health deterioration. These are exactly the factors that would be detected by comprehensive geriatric assessment (CGA).
But we found that junior medical officers in the ED, who see the vast bulk of the older patients, generally do not assess for these functions, and in this they were significantly different from more senior doctors (registrars and staff specialists) who do.
The DEED II study demonstrated that CGA for DEED resulted in improved cognitive and physical function and decreased admissions to hospitals, both within the initial one month and with ongoing benefit for 18 months.
MD Thesis Introduction 50
7. Linked medical issues
31. Caplan GA Harper E. Recruitment of volunteers to improve vitality in the elderly (The REVIVE Study). Internal Medicine Journal 2007; 37: 95-100.
[2.027; 3]
My role in this research This research was based on the HELP study by Sharon Inouye, but I modified the protocol to suit a lower rate of funding than Professor Inouye had available, so that the process could be managed with only one paid employee. I devised the hypothesis, obtained the funding, supervised the data collection performed by my Advance Trainee for her project, performed the analysis and provided considerable input to the writing.
How this research relates to the central theme This paper continues the theme of providing an alternative to standard in-hospital care, because the volunteer workforce changes the nature of in-hospital care to such a significant extent that it reduces the complications of hospitalization, decreasing the rate of delirium, another of my key themes. We also found it led to a decreased length of stay and, because it reduced delirium, we found it reduced the requirement for assistants in nursing to sit with acutely confused, agitated patients.
The significance of the work The results from the research convinced the administration of my hospital to continue funding the volunteer coordinator, beyond the pilot stage, so that our volunteer service has now been going since 2003. We are working with another hospital to attempt wider dissemination of the model, with a research framework.
MD Thesis Introduction 51
Background The original HELP study explored another angle of what has become a common theme for much of my research, namely delirium. The HITH and then the REACH OUT studies showed that home treatment prevents delirium. However, there are clearly many older patients that are not suitable for home treatment. For example, in the REACH OUT study we documented that only one in eight frail older patients in hospital was suitable for and consented to home treatment. So it is vital to also examine treatment modalities and care plans that reduce delirium in hospital. In this controlled before and after study we examined a modified version of the
HELP protocols originally developed by Professor Sharon Inouye when she was still at Yale.
We recruited volunteers from our surrounding community.
Key Findings
The REVIVE study found that implementation of a trained volunteer did reduce delirium, and enabled a reduction in the utilization of assistants-in-nursing (AINs) to “sit” with acutely agitated delirious patients. Combined with a finding of reduced length of stay in the patients who received the volunteer intervention, the scheme more than paid for itself, and POWH administration gladly continued the funding of this pilot project, so it is now an ongoing feature of the Geriatric ward at POW.
Consequences
The success of the REVIVE program was acknowledged by the receipt of an award from the
US, the 2008 Knight Steel Award. The citation read “in recognition of innovative implementation of evidence-based practice and excellence in the hospital care of older adults.
These efforts have been shown to improve patient outcomes and establish new international standards of quality in geriatric care. Presented by the HELP Dissemination program of
MD Thesis Introduction 52
Harvard Medical School and Yale University School of Medicine.” REVIVE was also a finalist in the 2006 NSW Health Baxter NSW Health Awards.
We are currently in negotiations with the John Hunter Hospital who wish to emulate the
REVIVE program, and we have jointly applied for research funding to evaluate how it would work in the ED.
Appendices: Editorials by others about my work
1. Hillman, KM. Restructuring hospital services. Medical Journal of Australia 1998; 169(5): 239. 2. Montalto, M. Hospital in the home: take the evidence and run. Medical Journal of Australia 1999; 170(4): 148-149. 3. Hertogh CMPM. Advance care planning and the relevance of a palliative care approach in dementia. Age Ageing 2006; 35: 553-4.
Although, please note that the reference to my work in editorial 3 accidentally omitted my name because of an error in the proof.
1 Commonwealth Department of Health and Family Services. Service delivery guides and selected case studies: Ambulatory Care Reform Program. Australian Government Publishing Service, Canberra 1997, p25-34. 2 Gray L, Dorevitch M, Smith R et al. Service provision for older people in the acute-aged care sytem: Final Report 2002. National Ageing Research Institute and Centre for Applied Gerontology. Melbourne 2002. 3 The National Demonstration Hospitals program - Review of Phase 1: 1995-1997. Commonwealth Department of Health and Family Services, Canberra, 1997. 4 Larkins RG, Martin TJ, Johnston CI. The boundaryless hospital – a commentary. Aust NZ J Med 1995; 25: 169-70. 5 Gilchrist WJ Newman RJ Hamblen DL Williams BO. Prospective randomised study of an orthopaedic geriatric inpatient service. Brit Med J 1988; 297: 1116-8. 6 Kennie DC Reid J Richardson IR Kiamara AA Kelt C. Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women: a randomised clinical trial. Brit Med J 1988; 297: 1083-6. 7 Sikorski JM Davis NJ Senior J. The rapid transit system for patients with fractures of proximal femur. Brit Med J 1985;290: 439-43. 8 Holmberg S Agger E Ersmark H. Rehabilitation at home after hip fracture. Acta Orthop Scand 1989; 60: 73-6. 9 Pryor GA Myles JW Williams DRR Anand JK. Team management of the elderly patient with hip fracture. Lancet 1988; I: 401-3. 10 Alberts KA Nilsson MH. Consumption versus needs of institutional care after femoral neck fracture. Scand J Rehab Med 1989; 21: 159-64. 11 Dolk T. Influence of treatment factors on the outcome after hip fractures. Upsala J Med Sci 1989; 94: 209-21.
MD Thesis Introduction 53
12 Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998; 280: 605-13. 13 Writing Group for the Women's Health Initiative Investigators, Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA 2002; 288; 321–333. 14 Campbell M Fitzpatrick R Haines A et al. Framework for design and evaluation of complex interventions to improve health. Brit Med J 2000; 321: 694-6. 15 NSW Health Acute Care Best Practice website www3.health.nsw.gov.au/clinpath/index.cfm?fuseaction=resources.dspliterature Unilateral Inguinal Hernia page and Clinical Pathways page, accessed 28-1-05 16 World Socialist Web Site published by the International Committee of the Fourth International, founded by Leon Trotsky www.wsws.org/news/1998/sep1998/hosp-s17.shtml accessed 28-1-05 17 Hillman K. Restructuring hospital services.(Editorial) Med J Aust 1998; 169: 239. 18 Montalto, M. Hospital in the home: take the evidence and run.(Editorial) Med J Aust Feb 15 1999; 170(4): 148-149. 19 Hospital-at-home care was at least as effective, safe, and acceptable as hospitalization for older adults [Abstract + commentary]. ACP Journal Club 1999 July August; 131: 7. Abstract of: Caplan GA, Ward JA, Brennan N, Board N, Coconis J, Brown A. Hospital in the Home: a randomised controlled trial. Medical Journal of Australia 1999; 170: 156-160. 20 Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care (Cochrane Review). In: The Cochrane Library , Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd. 21 Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care (Cochrane Review). In: The Cochrane Library , Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd. 22 Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. The Cochrane Database of Systematic Reviews 2003, Issue 4. 23 Shepperd S, Doll H, Angus RM, et al. Admission avoidance hospital at home. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD007491. DOI: 10.1002/14651858.CD007491. 24 Shepperd S, Doll H, Broad J, Gladman J, Iliffe S, Langhorne P, Richards S, Martin F, Harris R. Early discharge hospital at home. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000356. DOI: 10.1002/14651858.CD000356.pub3. 25 Marks L. Home and hospital care: redrawing the boundaries. Kings Fund Institute, 1991, London. 26 Neuberger J. Patients’ perspective. In Costain D and Warner M (eds) From hospital to home care: The potential for acute service provision in the home. King’s Fund Centre, London 1992. 27 Messanger A. Legal quandary over hospital in the home. Australian Doctor , 12 July 1996, p.4. 28 Debate: the elderly should not be admitted to hospital. Australian Doctor , 9 May 1997, p.53. 29 Saunders C. Hospital-in-home scheme slammed. Australian Doctor , 10 Sept 1999, p.14. 30 Larkins RG, Martin TJ, Johnston CI. The bopundaryless hospital – a commentary. Aust NZ J Med 1995; 25: 169-70. 31 Wilson RM, Runciman WB, Gibberd RW et al. The quality in Australian health care study. Med J Aust 1995; 163: 458-71. 32 Leff B, Burton L, Mader SL et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med 2005; 127: 989-95. 33 CanetJ, Raeder J, Rasmussen LS et al. Cognitive dysfunction after minor surgery in the elderly. Acta Anaesthesiol Scand 2003; 47: 1204-10. 34 Hertogh CMPM. Advance care planning and the relevance of a palliative care approach in dementia. Age and Ageing 2006; 35: 553-555. 35 Kleinfeld NR. Patients whose final wishes go unsaid put doctors in a bind. The New York Times July 19, 2003 p.B1. 36 Ward J Brown A Caplan G. Creating hospital beds – more efficient care of older orthopaedic patients: report of a project funded by the Commonwealth Department of Health, Housing and Community Services under the Medicare Incentive Program. Prince of Wales Hospital, Randwick, 1992.
MD Thesis Introduction 54 The published articles listed in the Table of Contents on page 1 have been removed from the digital copy of this thesis. Please see the print copy of the thesis for a complete manuscript. The Author's curriculum vitae has been removed from the digital copy of this thesis. Please see the print copy of the thesis for a complete manuscript. PUBLICATIONS 1. Caplan GA, Brigham BA. Marijuana smoking and carcinoma of the tongue. Is there an association? Cancer 1990; 66(5):1005-6. [Journal Impact Factor = 4.800; Citations on Web of Science at 30/1/2009 = 33 ] 2. Caplan GA. Marijuana and tongue cancer. Medical Aspects of Human Sexuality 1991; 25 (6) ; 32. 3. Caplan GA. Marijuana and mouth cancer. Journal of the Royal Society of Medicine 1991; 84: 386. [ 0.652; 2] 4. Lord SR, Caplan GA, Ward JA. Balance, strength and reaction time in non-exercising women: A pilot study. Archives of Physical Medicine and Rehabilitation 1993; 74 (8): 837-840. [ 1.734; 59] 5. Caplan GA, Lord SR, Ward JA. The benefits of exercise in postmenopausal women. Australian Journal of Public Health 1993; 17 (1): 23-26. [1.556; 20] 6. Lord SR, Caplan GA, Colagiuri R, Colagiuri S, Ward JA. Sensori-motor function in older persons with diabetes. Diabetic Medicine 1993; 10 : 614-618. [ 2.725; 34 ] 7. Caplan GA, Scane A, Francis RM. Pathogenesis of vertebral crush fractures in women. Journal of the Royal Society of Medicine 1994; 87: 200-202. [0.652;20] 8. Caplan GA, Colagiuri R, Lord SR, Colagiuri S, Ward JA. Exercise in older people with type II diabetes maintains bone density despite weight loss. Australian Journal on Ageing 1995; 14 (2): 71-75. [0.319;1 ] 9. Caplan GA, Brown A. Discharge Planning, Post Acute Care Services. Monograph - NDHP Booklet, Sydney 1995. 10. Caplan GA, Brown A. Post acute care: can hospitals do better with less? Australian Health Review 1997; 20: 43-54. [0.476; 4] 11. Brown A, Caplan G. A post-acute respiratory outreach service. Australian Journal of Advanced Nursing 1997; 14: 5-11. [0.592; ] 12. Caplan GA, Brown A, Croker WD, Doolan J. Risk factors for admission after Discharge of the Elderly from the Emergency Department - The DEED Study. Age and Ageing 1998; 27:697-702. [ 2.196; 16] 13. Caplan GA, Croker WD, Brown A. Recognition of deficits of physical and cognitive function in the elderly by medical staff in the emergency department. Emergency Medicine 1998; 10: 19-24. [0.82 ; 2] 14. Caplan GA, Brown A. Post acute care for all. Australian Health Executive 1998 Winter: 8- 11. 15. Caplan GA, Brown A, Crowe PJ, Yap S-J, Noble S. Reengineering the elective surgical service of a tertiary hospital: a historical controlled trial. Medical Journal of Australia 1998; 169: 247-251. [ 2.127;11 ] 16. Brennan NJ, Caplan GA. Attitudes to osteoporosis among elderly female orthopaedic patients. Osteoporosis International 1999;9:139-143. [ 4.216;5 ] 17. Caplan GA, Board N, Paten A, Tazelaar-Molinia J, Crowe PJ, Yap S-J, Brown A. The cost to the community of decreasing lengths of stay. Australian and New Zealand Journal of Surgery 1999; 69: 433-7. [ 0.783;13] 18. Caplan GA, Ward JA, Brennan N, Board N, Coconis J, Brown A. Hospital in the Home: a randomised controlled trial. Medical Journal of Australia 1999; 170: 156-160. [2.127; 59 ] 19. Lim K, Wren B, Jepson N, Roy S, Caplan GA. Effect of hormone replacement therapy on left ventricular hypertrophy. American Journal of Cardiology 1999; 83: 1132-4. [ 3.059; 25 ] 20. Veitch P, Rowland J, Caplan G. Geriatrics medical workforce: it’s the playing field not the goalposts! (letter) Fellowship Affairs 1999; 18: 5.
Appendices 258
21. Caplan GA. Hospital in the home programmes: safe and popular with patients and carers. Modern Medicine of Australia 1999; 42: 13-15. 22. Caplan G, Brown A. Clinical pathways (letter). Medical Journal of Australia . 1999; 170: 568. 23. Caplan GA, Brennan NJ, Brown A. Hospital in the home: a randomised controlled trial (letter) Medical Journal of Australia 1999; 171:110. 24. Hospital-at-home care was at least as effective, safe, and acceptable as hospitalization for older adults [Abstract + commentary]. ACP Journal Club 1999 July August; 131: 7. Abstract of: Caplan GA, Ward JA, Brennan N, Board N, Coconis J, Brown A. Hospital in the Home: a randomised controlled trial. Medical Journal of Australia 1999; 170: 156-160. 25. Caplan GA, Ward JA, Brennan N. Hospital-at-home care was at least as effective, safe, and acceptable as hospitalization for older adults. Evidence-Based Medicine 1999; 4(4): 114. 26. Board N, Caplan G. Implications of decreasing surgical length of stay, Australian Health Review 2000; 23(2): 71-85. 27. Board N, Caplan GA. Use of pathology services in re-engineered clinical pathways. Journal of Quality in Clinical Practice 2000; 20: 24-9. 28. Board N, Brennan N, Caplan GA. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Australian and New Zealand Journal of Public Health 2000; 24(3):305-311. [ ; 17 ] 29. Caplan GA. Evaluation of hospital at home scheme: another study found that patients prefer home care to hospital care. (letter) British Medical Journal 2000; 320: 1077. 30. Caplan G. Top 20 choice for geriatric medicine. (book review) Medical Journal of Australia 2001;175: 159. 31. Caplan G. Hospital in the nursing home. Insite : Australia’s Independent Aged Care Industry Newspaper 2002; 12: 5. 32. McCusker J, Verdon J, Caplan GA, Meldon SW, Jacobs P. Older persons in the emergency medical care system. Journal of the American Geriatrics Society. 2002; 50(12):2103-5. [3.479; 1] 33. Caplan G. Hospital in the home: principles and practice. (Book review) Medicine Today 2003; 4: 97. 34. Caplan GA, Harper EL. Australia is still aging well. (commentary) Journal of Gerontology: Medical Sciences 2004; 59A: 598-599. [3.500; 1] 35. Henderson A, Caplan GA, Daniel A. Patient satisfaction: the Australian patient perspective. Australian Health Review 2004; 27: 73-83. 36. Boxall A-m, Sayers A, Caplan GA. A cohort study of 7 day a week physiotherapy on an acute orthopaedic ward. Journal of Orthopaedic Nursing 2004; 8: 96-102. [2.06; 0] 37. Caplan GA, Williams A, Daly B, Abraham K. A randomised controlled trial of comprehensive geriatric assessment and follow up after discharge of elderly from the Emergency Department - The DEED II study. Journal of the American Geriatrics Society 2004; 52: 1417-1423. [ 3.479; 13] 38. Caplan GA, O’Sullivan R. A history to look forward to. (commentary) Journal of Gerontology: Medical Sciences 2004; 59A: 1159. [ 3.500; 1] 39. Boxall A-m Barclay L Caplan GA. Managing chronic obstructive pulmonary disease in the community: a randomised controlled trial of home based pulmonary rehabilitation for elderly, housebound patients. Journal of Cardiopulmonary Rehabilitation 2005; 25: 378- 385. [0.602;15] 40. Caplan GA, Coconis J, Woods J. Effect of Hospital in the Home treatment on physical and cognitive function: a randomised controlled trial. Journal of Gerontology: Medical Sciences 2005; 60: 1035-1038. [3.500; 2]
Appendices 259
41. Caplan GA Coconis J. Hospital in the Home and prevention of delirium. (Letter- on line) Annals of Internal Medicine 7 Dec 2005 http://www.annals.org.wwwproxy0.nun.unsw.edu.au/cgi/eletters/143/11/840 42. Caplan GA, Coconis J, Sayers A, Board N. Does home treatment affect delirium? A randomised controlled trial of Rehabilitation of Elderly and Care at Home Or Usual Treatment (The REACH OUT Trial). Age and Ageing 2006; 35: 60-65. [2.196; 3] 43. Caplan GA. Hospital in the home: a concept under question. (editorial). Medical Journal of Australia 2006;184: 599-600. [2.127; ] 44. Caplan GA, Meller A, Chan S, Squires B, Willett W. Advance Care Planning and Hospital in the Nursing Home. Age and Ageing 2006; 35: 581-5. [2.196; 1] 45. Wong DD Wong RPC Caplan GA. Self-rated health in the unwell elderly presenting to the emergency department. Emergency Medicine Australia 2007; 19: 196-202. [4.91;3] 46. Caplan GA Harper E. Recruitment of volunteers to improve vitality in the elderly (The REVIVE Study). Internal Medicine Journal 2007; 37: 95-100. [1.518; ] 47. Elder AT Caplan GA Meller A Squires B Chan S Willet W. Acute medical care for patients with advanced dementia - achieving a balance. Journal of the Royal College of Physicians Edinburgh 2007; 37: 30-31. 48. Caplan GA. Does Hospital in the Home treatment prevent delirium? Aging Health 2008; 4(1): 69-74. [0.61;] 49. Henderson EJ, Caplan GA. Home sweet home? Community care for older people in Australia. Journal of the American Medical Directors Association , 2008; 9(2): 88-94. [3.709 ;-] 50. Caplan G Kelly L. Rivastigmine transdermal patch for mild to moderately severe Alzheimer’s disease. Medicine Today 2008; 9: 69-70. 51. Chapman NH. Brighton T. Harris MF. Caplan GA. Braithwaite J. Chong BH. Venous thromboembolism - management in general practice. Australian Family Physician 2009; 38(1-2):36-40. 52. Meller AE Caplan GA. Let someone else decide? Development of an advance care planning service for nursing home residents with advanced dementia. Dementia 2009; 8(3): 391-406. [0.95;0] 53. Lim WK, Chong C, Caplan G, Gray L. Australian and New Zealand Society for Geriatric Medicine: Position Statement No. 15 Discharge Planning. Australasian Journal on Ageing 2009; 28 (3): 158-164. [0.83;0] 54. Kelly L, Caplan G. Delirium and long haul travel . Age and Ageing 2009; 38(6): 762. 55. Chapman NH. Brighton T. Harris MF. Caplan GA. Braithwaite J. Zylna zatorowosc zakrzepowa: postepowanie w warunkach praktyki lekarza rodzinnego (Venous thromboembolism) (Polish). Lekarz Rodzinny 2009; 142(6): 596-601. 56. Chapman NH. Brighton T. Harris MF. Caplan GA. Braithwaite J. Chong BH. Management of VTE in general practice. Phlebology Digest 2009; 22(3): 28-30. 57. Bolin T, Bare M, Caplan G, Daniells S, Holyday M. Malabsorption may contribute to malnutrition in the elderly. Nutrition 2010; 26: 852-3. 58. Caplan GA, Meller A. Home care for dying people (editorial). Journal of the American Medical Directors Association 2010; 11(1): 7-8. [3.709] 59. Caplan GA, Kvelde T, Lai C, Yap SL, Lin C, Hill MA. Cerebrospinal fluid in long lasting delirium compared to Alzheimer’s dementia. Journals of Gerontology: Medical Sciences 2010; 65A(10): 1130-6. 60. Caplan GA, Kelly L, McVeigh C. Hydration. Geriatric Medicine in General Practice 2010; 5(May): 4-5.
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ABSTRACTS PUBLISHED 1. Caplan GA, Colagiuri R, Lord SR, Colagiuri S, Ward JA. The effects of exercise on bone density in elderly people with non insulin dependent diabetes (Abstract). Age and Ageing 1993; 22(Suppl 3): 10. 2. Caplan GA, Bennet MK, Barer MR, James OFW. Helicobacter pylori cause bacterial contamination of the small bowel (Abstract). Australian and New Zealand Journal of Medicine 1994; 24 (4): 422. 3. Caplan GA, Brown A, Croker WD, Doolan J. The Discharge of Elderly from the Emergency Department (DEED) Study (Abstract). Australian and New Zealand Journal of Medicine 1995; 25(5): 594. 4. Brennan NJ, Caplan G. Attitudes to osteoporosis among elderly female orthopaedic patients. (Abstract) Australian and New Zealand Journal of Medicine 1996; 26(4): 586. 5. Caplan GA. Post acute care: national and international perspectives (Abstract). Australian and New Zealand Journal of Medicine 1998; 28: 503. 6. Caplan G, Timmiss P, Brown A. How can we help older patients after the emergency? (Abstract) Journal of the American Geriatrics Society 2000; 48(8); S8. 7. Caplan GA, Timmiss P, Abrahams K, Brown A. Discharge of elderly from the emergency department – The DEED II Study. (Abstract) Gerontology 2001; 47(suppl 1): 114. 8. Caplan GA, Brown A, Croker WD, Doolan J. Risk of admission within four weeks of discharge of elderly from the emergency department – The DEED I Study. (Abstract) Gerontology 2001; 47 (Suppl 1): 115. 9. Boxall A, Barclay L, Sayers A, Caplan G. A randomised controlled trial of home-based pulmonary rehabilitation with COPD patients aged over 60 years. (Abstract) Thorax 2003; 58: Suppl iii 76. 10. Caplan G, Coconis J, Sayers A, Woods J. A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment: the REACH OUT trial. (Abstract) Internal Medicine Journal 2004; 34 (Suppl.): A47. 11. Caplan G, Boxall A-m, Barclay L, Sayers A. A randomised controlled trial of pulmonary rehabilitation for homebound older patients. (Abstract) Internal Medicine Journal 2004; 34 (Suppl.): A59. 12. Harper E, Harris J, Fuchter E, Beer C, Caplan GA. Recruitment of volunteers to improve health in the elderly (REVIVE). (Abstract) Internal Medicine Journal 2005 (Suppl.); 35: A50. 13. Caplan G. From Gomer to core business: the older patient in ED. Emergency Medicine Australasia 2005; 17: A5-A6. 14. Budge MM, Celler B, Lovell N, Caplan G, Srikusalanukul W, Gravenmaker K, Perkins D, Basilakis J. Trial deployment of a clinical monitoring and management system for residential aged care facilities (RACFS). Internal Medicine Journal 2006; 36(Suppl. 5): A180. 15. Caplan G. Best care for nursing home residents. Internal Medicine Journal 2006; 36(Suppl. 5): A184. 16. Caplan GA, Kvelde T, Hill MA. An investigation of delirium. Internal Medicine Journal 2007; 37 (Suppl. 3): A68. 17. Bolin T, Bare M, Caplan G, Daniells S, Petocz P, Holyday M. Malnutrition screening in the hospitalised elderly: a randomised controlled trial. Internal Medicine Journal 2007; 37 (Suppl. 3): A71. 18. Bare M, Holyday M, Caplan G, Daniells S, Bolin T. Improving identification of malnutrition in acute aged care. Internal Medicine Journal 2007; 37 (Suppl. 3): A84.
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19. Caplan GA. Meta-analysis of hospital in the home (HITH): the effect of substituting care at home for care in hospital. Journal of Nutrition Health & Ageing 2009;13 (Suppl 1): S85. 20. Caplan GA Sulaiman NS, Mangin DA, Aimonino Ricauda N, Wilson AD, Barclay L. Is Hospital in the Home a good option for older people? Journal of the American Geriatrics Society 2010; 58(4 Suppl): S7. 21. Caplan GA, Kvelde T, Lin C, Yap SL, Lai C, Hill MA. Cerebrospinal fluid in delirium compared to Alzheimer’s dementia. Journal of the American Geriatrics Society 2010; 58(4 Suppl): S35-6.
UNPUBLISHED CONFERENCE PAPERS Caplan GA Finnegan T. The Rehabilitation Assessment Form: reliability and validity. Australian Geriatrics Society Annual Scientific Meeting Sydney 1985.
BOOK CHAPTERS 1. Boxall A-m, Caplan G, Sayers A. “Home pulmonary rehabilitation with COPD patients over 60 years of age” in National Demonstration Hospitals Program Phase 3 Health Service Research Reports. Commonwealth Department of Health and Aged Care, Canberra 2001 ISBN 0642503508. 2. Caplan G, Priddin D, DeLisser T, Sayers A “Rehabilitation of the Elderly and care at Home Or Usual Treatment (REACH OUT)” in National Demonstration Hospitals Program Phase 3 Health Service Research Reports. Commonwealth Department of Health and Aged Care, Canberra 2001 ISBN 0642503508. 3. Board N, Brennan N, Caplan GA. “A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients” in National Demonstration Hospitals Program Phase 3: A resource for integrating health services. Commonwealth Department of Health and Aged Care, Canberra 2001 ISBN 0642503532. 4. Barclay L, Boxall A-m, Sayers A, Caplan G. A randomised control trial of home-based pulmonary rehabilitation for elderly patients. In Nursing Monograph 2003, Nursing Education and Research Unit, Sydney 2003. ISSN 1448-2745. 5. Caplan GA. Hospital in the nursing home and advance care planning. In Baxter 2004 NSW Health Awards: winners and finalists. NSW Department of Health, Sydney 2004. ISBN 0734737564. 6. Coconis J Fairbrother G Caplan G. Cephazolin administration in the home-based treatment of cellulitis. In Nursing Monograph 2005, Nursing Education and Research Unit, Sydney 2005 ISSN 1832-6021. 7. Gammack JK Caplan GA Ghosh K. Systems of health care: the United Kingdom, the United States and Australia. In Principles and Practice of Geriatric Medicine 4 th Edn, John Wiley & Sons, Chichester 2006. ISBN 13 978-0-470-09055-8.
CONFERENCE PROCEEDINGS 1. ‘The benefits of exercise in post-menopausal women’ in Coast Medical Association Proceedings: Abstracts for the Tow research awards. Vol II: 1989-93. 2. ‘Planning for discharge’ in Efficiency in the Australian health system – rhetoric or reality. The St George Hospital Division of Surgery 1997. 3. ‘The POW model of healthcare integration’ in the NDHP3 – A Dynamic Healthcare Partnership Conference ANU Canberra 1999.
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4. Hospital in the Home Tool Kit Seminar Proceedings. Australian Resource Centre for Hospital Innovations 1999. 5. ‘No place like Home’ Views on Ambulatory Care, Conference Notes. Health Care of Australia, 1999. 6. ‘Discharge of Elderly from the Emergency Department- The DEED II Study’ in the NDHP Mid-Term Conference Collection of Presentations 2000. 7. ‘The Post Acute Respiratory Outreach Service’ National Chronic Disease Self- Management Conference 2000 Proceedings. 8. ‘From perm wave to nu wave’ National Conference on Volunteering 2008 Proceedings published on line at http://www.volunteeringaustralia.org/files/MOD1KC1A8C/bn08023_VA8_Salle- Ann%20Ehms.pdf
INVITED SPEAKER 1. “Satisfaction and the Elderly in the Emergency Department” Seminar on Health-Related Consumer Feedback and Discharge Planning. Adelaide 15 November 1995 2. “Patient satisfaction - measuring consumer satisfaction” National Demonstration Hospitals Program Lead Hospitals Seminar. Royal Melbourne Hospital 27 November 1995 3. “Risk factors for readmission” DEED Conference: From GOMER to DEED: Discharge of Elderly from the Emergency Department” Sydney 1 December 1995. 4. “Home is where the health is.” Discharge Planning and Post Acute Care - Seminar of the Hospital and Health Services Association of South Australia in Adelaide 29 February 1996. 5. “Discharge Planning and Post Acute Care.” Best Practice Managing Elective Surgery, The Royal Melbourne Hospital, Melbourne 14 June 1996. 6. “What did we want to change and what did we find out?” The Challenge of Elective Surgery - NDHP Meeting, Mater Hospital, Brisbane 25-26 July 1996. 7. “Post Acute Care in the Teaching Hospital” Annual Meeting of Hospital and Health Services Association of South Australia in Adelaide 22 August 1996. 8. Participant - Commonwealth Department of Health and Family Services Ambulatory Care Reform Program - Technical workshop on Pre-admission and Post Acute Care. Melbourne 12 September 1996 9. Participant – Commonwealth Department of Health National indicators of quality of care and health outcomes. Seminar and workshop Canberra 6-7 November 1996. 10. “Getting the patient home’ National Demonstration Hospitals Program Surgeons Meeting, Melbourne 14 Nov 1996 11. “Discharge processes” Driving Health Reform: the Surgical Process Conference, Liverpool Hospital, 6-7 Mar 1997 12. “Hospital in the Home’ Prince of Wales Hospital Grand Rounds, 14 May 1997. 13. “Planning for discharge” Efficiency in the Australian Health System – Rhetoric or Reality? Conference, St George Hospital, Sydney, 15 May 1997. 14. “Hospital in the Home” Nepean Hospital Grand Rounds, 31 July 1997. 15. “Hospital in the Home: a randomised controlled trial” British Geriatrics Society Spring Meeting, London England , 8-10 October 1997. 16. “Hospital in the Home in Australia” World Congress on Homecare and Hospice, Boston USA 17-22 October 1997. 17. “Dementia – an overview” Royal Hospital for Women Seminar on Hormone Replacement Therapy 21 February 1998. 18. “Systemic improvements to post acute care and discharge planning” PATCH Conference, Sydney, 31 July 1998
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19. “Hospital in the Home” Making the beds go around – Integrated Bed Management Conference, Newcastle 3-4 August 1998. 20. “Discharge processes/blocks” Driving Health Reform Conference, Liverpool Hospital 13- 14 August 1998. 21. “Health Outcomes” The Victorian Healthcare Association Annual Conference, Melbourne 19-20 November 1998. 22. “Research from the NDHP” Committee of Presidents of Medical Colleges Workshop, Sydney 10 February 1999. 23. “Women are from Venus and men die early: What constitutes normal ageing in a male?” Men’s Business Conference Bondi Beach 25 February 1999. 24. Participant - DHIP (Divisions and Hospitals Integration Program) Planning Workshop, Sydney 19 March 1999. 25. “Hospital in the home: a randomised controlled trial” Hospital in the Home Conference Randwick 6-7 May 1999. 26. “The Prince of Wales model of Post Acute Care and Hospital in the Home”, Sir Charles Gairdner Hospital, Perth , 10 May 1999. 27. “Home is where the health is” Hospital in the Home Tool Kit Seminar, Adelaide 14 May 1999. 28. “There’s no place like home” Keynote Speaker at Healthcare of Australia Conference on Ambulatory Care, Melbourne 5 August 1999. 29. Participant, Australian Resource Centre for Hospital Innovation Strategic Planning Day 31 August 1999. 30. “Acute Care in the Community” and “Plenary- Reflective, Response Session” at Divisions Hospital Integration Program (DHIP) Showcase Conference, 25 November 1999. 31. “Prince of Wales Hospital: NDHP Lead Hospital” to the Queensland Statewide Clinical Innovation Network videoconference 16 December 1999. 32. “Discharge Planning in Hospital” at DVA Discharge Planning Workshop Sydney 15 February 2000 33. “Post acute care and Hospital in the Home” Newcastle Mater Hospital Grand Rounds, Newcastle 23 February 2000. 34. “Hospital in the Home” Royal North Shore Hospital Geriatric Grand Rounds, 25 February 2000. 35. “Discharge of Elderly from the Emergency Department II” at The Hospital Community Interface Tool Kit Seminar, Perth 16 March 2000. 36. “Hospital in the Home for GPs” Osborne Division of General Practice Seminar, Perth 17 March 2000. 37. “Discharge Planning: good for patients and the hospital” at DVA Discharge Planning Workshop Sydney 22 March 2000 38. “DEED II” Many rivers to cross: Integration in NDHP III Conference. Melbourne 10-11 April 2000. 39. “Hospital at Home” St George Hospital, Geriatric Grand Rounds, 26 April 2000. 40. “What can we do to improve care of the elderly in the Emergency Department – The DEED II study. American Geriatrics Society Annual Scientific Meeting, Nashville USA 19 May 2000. 41. “How to help older patients in the ED – the DEED II study” Australian Society for Geriatric Medicine Annual Scientific Meeting, Cairns 5 July 2000. 42. “Typical cases of atypical dementia” Prince of Wales Hospital Grand Rounds 4 October 2000 “PACS” South Eastern Sydney Division of General Practice, 5 October 2000. 43. “NDHP3 patients and the use of MBS EPC items” Capricornia Division of General Practice, Rockhampton , 10 October 2000.
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44. “The REACH OUT: Preliminary results of a RCT of home rehabilitation” Flinders NDHP Conference, Adelaide 27 October 2000. 45. “Post acute care and hospital in the home” Alice Springs Hospital Grand Rounds 17 November 2000. 46. “Publishing your project” Sustaining your achievements NDHP conference. ANU Canberra , 21 November 2000. 47. “Randomised controlled trial of Hospital in the Home” Seminar on Outpatient Parenteral Antibiotic Therapy: A Global Perspective, at the 7 th Western Pacific Congress of Chemotherapy & Infectious Diseases. Hong Kong 13 December 2000. 48. “The impact of health service reform on health outcomes” at the NDHP 3 Integration: Results & Recommendations Conference, Sydney 22 March 2001. 49. “Preliminary results of REACH OUT” at the NDHP 3 Integration: Results & Recommendations Conference, Sydney 22 March 2001. 50. Opening Speaker “Comparing the cost effectiveness of hospital care to home care” at the Hospital in the Home Congress, Sydney 1 May 2001. 51. “Panel Discussion: Understanding the pros and cons of home care treatment” at the Hospital in the Home Congress, Sydney 2 May 2001. 52. “Post acute care” at the Royal Australian College of Physicians Annual Scientific Meeting Sydney 16 May 2001. 53. “The why, when, where, & how of case conferencing with GPs around chronic and complex management” South Eastern Sydney Division of GPs. 22 May 2001 and 27 June 2001. 54. “Demonstrating project achievements” at the Demonstrating Integration Outcomes Conference, Fremantle WA 24 May 2001. 55. “Economics of OPAT” at the Emergency Medicine in the New Millenium, Leura NSW, 25 June 2001 56. Seminar of assessment and intervention for high risk seniors in the emergency department: cross national perspectives. 17 th Congress of the International Association of Gerontology, Vancouver Canada 1-6 July 2001. 57. Seminar on research and Hospital in the Home. Australian Home and Outpatient Intravenous Therapy Association Sydney 31 August 2001. 58. “Home is where the health is”. ARCHI Toolkit Seminar on Hospital Innovations for Older Patients, Adelaide 29 October 2001 59. “Hospital in the Nursing Home” at the Aged & Community Services Annual Conference Sydney 1 November 2001. 60. “Hospital in the Nursing Home Program” Tri State Conference of Aged & Community Services Association Mildura 25 February 2002. 61. “Anaemia in the elderly” Symposium for RACP advanced trainees, Sydney 11 April 2002. 62. “Post acute care and hospital in the home” presentation to the Acute Care Implementation Group, Department of Health, North Sydney, 11 April 2002. 63. Panel discussion. “Funding for home care services – public and private” Hospital in the Home Congress Sydney 29 April 2002. 64. “Bringing hospital care into the nursing home” Hospital in the Home Congress Sydney 30 April 2002. 65. Panel Discussion: “Issues in disease management” Victorian Centre for Ambulatory Care Innovation Annual Conference Melbourne 25-26 th July 2002. 66. “Hospital in the Nursing Home” Victorian Centre for Ambulatory Care Innovation Annual Conference Melbourne 25-26 th July 2002. 67. “Discharge Planning Workshop” Hospital in the Home Congress Sydney 7 April 2002
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68. “Improving outcomes for older patients in the emergency department” Making the hospital system work for older people Department of Human Services seminar, Melbourne 12 December 2002 69. “Advances in Home Rehabilitation” Hospital in the Home Congress Sydney 9 April 2003 70. “Introduction to Geriatric Medicine” Combined Hospitals Meeting, Ekaterinburg, Russia 27 th May 2003 71. “Rehabilitation for frail elderly” Combined Hospitals Meeting, Ekaterinburg, Russia 28 th May 2003 72. “Beds or big picture” at Newcastle Institute of Public Health Seminar, Newcastle 22 nd July 2003 73. “Discharge of elderly from the emergency department” at National Symposium on Ageing Research Canberra 23-25 th September 2003 74. “Prevention of Delirium” Academic Department of Old Age Psychiatry, Prince of Wales Hospital 8 th October 2003. 75. Keynote Speaker “Show me the way to go home” Ambulatory Care Conference, Liverpool, Australia 28 November 2003. 76. “Alternatives to hospitalisation” Royal Australasian College of Physicians Annual Scientific Meeting, Canberra 19 May 2004. 77. “Advance Care Planning: The POW program” Illawarra Area Health Service Advance Care Planning Workshop. Wollongong 7 July 2004. 78. “You can’t prevent falls” debate at Osteoporosis Australia Clinical Update Day 16 th August 2004, Sydney. 79. “Managing dementia in the home” Ageing at Home Conference, Sydney 10 September 2004. 80. “Hospital in the Home for the older person” Ageing at Home Conference, Sydney 10 September 2004. 81. Plenary Speaker . “Ageing in the ED”. Australian College of Emergency Medicine Annual Scientific Meeting Adelaide 23 rd November 2004. 82. Opening Speaker . “Functional outcomes and Hospital in the Home.” 5 th Hospital in the Home Conference. Sydney 27 th April 2005. 83. “Aged Care Initiatives” presentation to the Hon. Morris Iemma, NSW Minister of Health 17 May 2005. 84. “RCTs of Hospital in the Home” + symposium coordinator, International Association of Gerontology, Rio de Janeiro, Brazil 29 June 2005. 85. “EBM for care of older patients in the ED.” St George Hospital Geriatric Grand Rounds 27 July 2005. 86. “Osteoporosis, falls and fractures in older people.” Osteoporosis Australia Framework for GPs Sydney 27-8-05. 87. Keynote Address “Hospital care outside of the hospital: Home is where the health is” to Geriatrics beyond the boundaries conference Brisbane 8-9 September 2005. 88. “Start, REVIVE, Survive” to Geriatrics beyond the boundaries conference Brisbane 8-9 September 2005. 89. “Why transfer to hospital?” Aged and Community Services Australia National Conference Canberra 13 th September 2005. 90. “Prevention of delirium” Fellowship of Psychiatry of Old Age Seminar on “Prevention of Mental Disorders in Late Life,” Sydney 4 th November 2005. 91. “HITH and Rehabilitation in the Home” at “The Principles of Ambulatory Care” Department of Health Clinical Senate, Perth 25 November 2005. 92. “Polypharmacy in the elderly” SES Division of General Practice 16 Feb 2006. 93. “Pathophysiology of delirium” Anatomy Seminar UNSW 27 April 2006. 94. “Diagnosis of dementia” to GP Seminar Sydney 20 May 2006.
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95. “Developing and deploying a successful flow program with sustainable results” at Optimising Patient Flow Summit 2006 Sydney 29 June 2006. 96. “Medicine for our senior years” to the Friends of the Hebrew University Sydney 26 July 2006. 97. “Best care for nursing home residents.” Breakfast meeting, Australian Society for Geriatric Medicine Annual Scientific Meeting, Christchurch New Zealand 5 Sept 2006. 98. “Aged Care HITH” CAPAC & HITH Seminar Sydney 30 October 2006. 99. “Clinical Governance in HITH” NSW Health Performance Review 2006, 4 Dec 2006. 100. “A volunteer program for the geriatric ward” Wollongong Hospital Geriatric Department Grand Rounds, 20 Dec 2006. 101. “Advance Care Planning in the community” NSW Health ACP Workshop, 9 March 2007. 102. “Developing comprehensive Advance Care Planning” Redesigning Healthcare for the Ageing Population Summit 28 Mar 2007. 103. “Establishing a CAPAC service” NSW Metropolitan Hospitals General Managers Meeting, 12 April 2007. 104. “CAPAC in the nursing home” NSW Health Winter How To workshop, 8 May 2007. 105. “Healthcare redesign: fundamentals for aged care” Optimising Patient Flow 07 Brisbane 5 June 2007. 106. “Nutrition for the older person” SIGPET Workshop for GPs, Holiday Inn Coogee 26 Jun 2007. 107. “The SESIAHS experience – ACP in the Nursing Home” North Coast Area Health Service Advance Care Planning Workshop. Ballina 31 st July 2007 108. Keynote address “A rise in the need for palliative care in residential aged care: carefully planning for end-of-life care” at Redesigning Healthcare for Older Australians Melbourne 23 rd Aug 2007. 109. “An investigation of delirium” at Australian and New Zealand Society for Geriatric Medicine Adelaide 6th Sept 2007. 110. Keynote address “A meta-analysis of Hospital in the Home” at CAPAC & HITH 2007: Moving Forward Conference, Sydney 25 th Oct 2007. 111. “Turning a bad deal into a good DEED: Discharge of Elderly from the Emergency Department” at the Annual Scientific Meeting of the Canadian Geriatrics Society, Montreal, Canada 11 th April 2008. 112. “Diabetes and the older patient” SIGPET Workshop for GPs, Crowne Plaza Coogee 1 May 2008. 113. “Where is the (advance care) plan? St George Hospital Geriatric Grand Rounds 7 May 2008. 114. “Hospital in the Home for older patients” APAC-Aged Care Steering Committee, Macquarie Hospital 5 th June 2008. 115. “Research: Delirium prevention through HITH” Hospital in the Home Conference 2008 Melbourne 25 th June 2008. 116. “Advance Care Planning with an emphasis on nursing homes” Sir Charles Gairdner Hospital Geriatric Grand Rounds Perth 11 th Aug 2008. 117. “Progress in Hospital in the Home” Mercy Hospital Perth 12 th August 2008. 118. “From GOMER to DEED: progress in aged care in the Emergency Department” Medical Grand Rounds, Royal Perth Hospital Perth 13 th Aug 2008. 119. “Delirium” ICU Grand Rounds, Prince of Wales Hospital 20 Aug 2008. 120. “Advance Care Planning” The Westmead Hospital Week Aged Care Symposium 27 th Aug 2008. 121. “Advance Care Planning in Discharge Planning” Discharge Planning Association Biennial Conference, Sydney 24 th October 2008.
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122. “Is Hospital in the Home good for patients?” APAC + Manly-Warringah Division of General Practice Conference 26 th March 2009. 123. “Stop playing with my delirium” POWH Grand Rounds, 20 th May 2009. 124. “Hospital in the Home for older patients” to delegation from Singapore Department of Health, POWH, 1 st June 2009. 125. “Does Hospital in the Home affect readmission rates?” Hospital in the Home Conference, Melbourne 17 th June 2009. 126. “Meta-analysis of substitutive Hospital in the Home” International Association of Gerontology and Geriatrics, Paris France 7th July 2009 127. “Carers in Geriatric Medicine” South Eastern Sydney Division of General Practice 28 th July 2009. 128. “The REVIVE Program” John Hunter Grand Rounds, Newcastle 24 th Sept 2009. 129. “Enquiries into the pathophysiology of delirium” 4 th Scientific Congress on Delirium, Leeds, England 9th Oct 2009. 130. “Post Discharge Care” ANZSGM Advanced Trainees Spring Education Weekend Sydney 17 th Oct 2009. 131. “Is readmission a useful indicator for hospital in the home?” 2 nd Annual Hospital in the Home Society Conference, Sydney 6 th Nov 2009. 132. “Expert panel debate – Current controversies in HITH” 2 nd Annual Hospital in the Home Society Conference, Sydney 6 th Nov 2009. 133. “Barriers to care integration: What solutions are needed?” Panel Discussion Changi General Hospital Annual Scientific Meeting Singapore , 14 th Nov 2009. 134. Keynote Speaker “To REACH OUT or to give a good DEED?” Singapore Geriatric Medical Society Biennial Scientific Conference, Singapore , 15 th Nov 2009. 135. “Confusion across the Continuum: Delirium and its challenges across the care continuum.” Singapore Geriatric Medical Society Biennial Scientific Conference, Singapore , 15 th Nov 2009. 136. “PACS” Department of Health Workshop on Model of Care for keeping older people healthy at home. North Sydney 2 nd Dec 2009. 137. “Is Hospital in the Home a good option for older people?” American Geriatric Society Annual Scientific Meeting, Orlando USA 14 th May 2010. 138. Keynote Speaker “Advances in Hospital in the Home” Whangarei, New Zealand 28 th May 2010.
POSTERS 1. The Post Acute Care Respiratory Outreach Service. First National Conference on Chronic Disease Self Management . Sydney 31/7-1/8/2000. 2. Boxall A-M Barclay L Caplan GA. Home based pulmonary rehabilitation – successfully managing COPD at home. Victorian Centre for Ambulatory Care Innovation Annual Conference Melbourne 25-26 th July 2002. 3. Caplan GA, Meller A, Chan S, Squires B, Willett W. Controlled trial of Advanced Care Planning in Nursing Homes in Australia. American Medical Directors Association Annual Scientific Meeting . New Orleans 16 th -20 th March 2005. 4. Caplan GA, Coconis J, Sayers A, Board N, Woods J. Does home treatment prevent delirium? Delirium: More attention, less confusion: International conference for delirium researchers. Durham, NC 20-21 April 2006 5. Budge MM, Celler B, Lovell N, Caplan G, Srikusalanukul W, Gravenmaker K, Perkins D, Basilakis J. Trial deployment of a clinical monitoring and management system for residential aged care facilities (RACFS). Australian Society for Geriatric Medicine Annual Scientific Meeting, Christchurch New Zealand 5 Sept 2006.
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6. Caplan GA Harper EL Harris J Ehms S-A. REVIVE: Recruiting Volunteers to Improve Vitality in the Elderly. GMCT Aged Care Forum ‘Complex People in a Complex System ’. Westmead 1 Dec 2006. 7. Bolin T, Bare M, Caplan G, Petocz P, Holyday M. Malnutrition in the hospitalised elderly: A randomised controlled trial of nutritional intervention on length of stay, weight change and readmission rates. American Gastroenterological Society Digestive Diseases Week Washington DC USA 19-24 May 2007. 8. Bare M, Holyday M, Caplan G, Daniells S, Bolin T. Improving identification of malnutrition in acute aged care. Australian and New Zealand Society for Geriatric Medicine Annual Scientific Meeting Adelaide 5-8th September 2007. 9. Caplan GA, Kvelde T, Lin C, Yap SL, Lai C, Hill MA. Cerebrospinal fluid in delirium compared to Alzheimer’s dementia. Journal of the American Geriatrics Society Annual Scientific Meeting Orlando USA 13 th May 2010
RESEARCH PROJECTS/GRANTS RECEIVED 1. Caplan GA Brown A & Croker WD., Discharge of Elderly from the Emergency Department (The DEED Study) 1994-5. The project was supported by a grant of $50,000 from the Commonwealth Department of Human Services and Health, National Hospital Quality Management Program. 2. Caplan GA Brown A Crowe P Yap S-J Noble S., Resource implications for community health care services arising from a reduction in length of hospital stay 1995-7. This project was supported by a grant of $300,000 from the Commonwealth Department of Human Services and Health Hospital Access Program (HAP). 3. Caplan GA Ward JA Brown A. Hospital in the Home 1995-7. This project was supported by a grant of $240,000 from the Commonwealth Department of Human Services and Health. 4. Brennan N & Caplan GA. Use of anti-osteoporotic medication in women with fractured necks of femur. 1995-6. Women who suffer a fractured neck of femur are still reluctant to take anti-osteoporotic medication. This project evaluated an education program. 5. Caplan GA & Brown A. N ational Demonstration Hospital Program 1995-7. The Post Acute Care Service has been recognised as a “lead hospital” in discharge planning and post acute care and received a grant of $1.45 million from the Commonwealth Department of Human Services and Health to fund this role as well as to allow service expansion. The expansion project is the Discharge of Elderly from the Emergency Department (DEED) II 1996-9. This is a randomised controlled trial enrolling 750 subjects to study the effects of acute intensive intervention by a multidisciplinary team after DEED. 6. Lim K Roy S Jepson N Wren B Caplan GA. A case-control study of the effect of long term hormone replacement therapy on left ventricular dimensions. HRT decreases cardiovascular mortality by about 50%. Only 35% of this effect is due to the well known effects of HRT on lipids. Previous studies have demonstrated that HRT can improve cardiovascular haemodynamics but it is suspected, although never shown, that long term HRT will also decrease left ventricular hypertrophy. 7. Caplan GA Brown A. National Demonstration Hospital Clearing House Satellite. Grant of $18,500.1998 8. Caplan GA & Brown A. N ational Demonstration Hospital Program Phase III 1999- 2000. The Post Acute Care Service has been recognised as a “lead hospital” in integrating care and received a grant of $1.44 million from the Commonwealth Department of Health and Aged Care to fund this role as well as to allow service expansion.
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9. Caplan GA Brown A. Australian Resource Centre for Hospital Innovation (ARCHI) Satellite . Extension grant of $13,000. 1999 10. Caplan GA. Australian Resource Centre for Hospital Innovation (ARCHI) Satellite . Extension grant of $13,000. 2000 11. Caplan GA Boxall AM Wright R. A randomised controlled trial of in home pulmonary rehabilitation for elderly patients with COPD. Most pulmonary rehabilitation programs are conducted for hospital outpatients. However this excludes the most severely affected patients who are unable to come to outpatients for the program. 12. Caplan GA Meller A. Advance Care Directives and Hospital in the Nurisng Home . NSW Department of Health $210,000. 2000-2002 13. Caplan GA. Australian Resource Centre for Hospital Innovation (ARCHI) Satellite . Extension grant of $20,000. 2001 14. Caplan GA Woods J & Williams A. National Demonstration Hospital Program Phase IV 2002-03. The Post Acute Care Service has been recognised as a “lead hospital” in hospital based care of older patients and received a grant of $1.1 million from the Commonwealth Department of Health and Aged Care to fund this role as well as to allow service expansion. 15. Caplan GA. Australian Resource Centre for Hospital Innovation (ARCHI) Satellite . Extension grant of $20,000. 2002 16. Caplan GA. Australian Resource Centre for Hospital Innovation (ARCHI) Satellite . Extension grant of $20,000. 2003 17. Caplan GA Woods J Coconis J. Ambulance Service of NSW Residential Care Response Service $50,000. 2004. 18. Cellar B Budge M Caplan G. Trial deployment and evaluation of a clinical monitoring and care management system for residential care facilities 2004-06. Grant from Commonwealth Department of Health and Ageing Clinical IT in Aged Care Program $302,500. 19. Boxall AM Barclay L Caplan GA. Randomised controlled trial of psychological support for Chronic Obstructive Pulmonary Disease. Anxiety and other psychological problems are a prominent feature of many chronic diseases. 20. Bolin T Holyday M Caplan GA. Randomised nutritional intervention on an acute aged care ward 2005-07. Gut Foundation and Pharmatel Fresenius Kabi $240,000. 21. Caplan GA Hill MA Kvelde T. Investigation into the pathophysiology of delirium. 2006- . 22. Zwar N Dennis S Griffiths R Perkins D Caplan GA Harris M May J. Optimising skill-mix in the primary health care workforce for the care of older Australians 2006-07 . Grant from the Australian Primary Health Care Research Institute $194,503 23. Prof RA Iedema; A/Prof E Manias; Dr BB Lee; A/Prof MD Buist; A/Prof GA Caplan; Dr M Kornberger; Ms JF Carthey; Dr R Sorensen; Dr CM Jorm; Prof FD Becker. Examining organisational complexity and clinical risk to improve hospital patients' safety 2008-10 . Australian Research Council Discovery Project, Grant ID# DP0879002, $475,000. 24. Holyday M, Daniels S, Bolin T, Caplan G. Treating malnutrition at home – a study to investigate whether the GMCT HEN Guidelines improves patient outcomes and health system efficiency . Greater Metropolitan Clinical Taskforce $132,000. 25. Agar M, Caplan GA. Randomised control trial of risperidone versus haloperidol versus placebo with rescue haloperidol in delirium in palliative care 2009-10. NHMRC Project Grant ID# 480476 $50,000.
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CONFERENCES AND VISITS ORGANISED • May 1994 Australian Society for Geriatric Medicine Annual Scientific Meeting in Hobart, Member - Education Committee • 1 December 1995 “From GOMER to DEED: Discharge of Elderly from the Emergency Department” - a one day conference at Prince of Wales Hospital. • 22-24 January 1997 “End of NDHP” Combined Mater Brisbane and Prince of Wales Hospitals Consortia Conference. • August 1997 Visit of Davis Coakley, Professor of Geriatric Medicine at Trinity College, Dublin to Sydney • May 1998. Visit of David Reuben, Professor of Geriatrics at UCLA to Sydney. • “Home is where the health is: a 1.5 day conference on Hospital in the Home, Prince of Wales 6-7 May 1999. • May 1999. Visit of John Morley, Professor of Geriatrics at St Louis University, Missouri to Sydney. • 14 May 1999. ARCHI Tool Kit seminar on Hospital in the Home, Adelaide Stamford Plaza Hotel. • 16 March 2000. The Hospital Community Interface ARCHI Tool Kit Seminar, Perth. • July 2000. Visit of Rose Anne Kenny, Professor of Cardiovascular Research at Newcastle- upon-Tyne University to Sydney. • 21-23 March 2001. NDHP 3 Integration: Results & Recommendations Conference, Sydney Convention and Exhibition Centre, Darling Harbour. • Australian Society for Geriatric Medicine Annual Scientific Meeting in Leura, NSW,23-25 May 2001. Member – Organising Committee. • June 2003 Visit of Professor Ken Rockwood and A/Prof Bruce Leff to Sydney. • August 2003 Visit of Professor Jane McCusker to Sydney. • 6-8th August 2003. A Better Third Age: Healthcare for older people conference, in Brisbane. • September 2004 Visit of Dr Elias Papazissis, Director of Hospital in the Home in Athens, Greece, to Sydney. • June 2005 Visit of Professor Simon Lovestone, Institute of Psychiatry, London, to Sydney. • June 26-30, 2005, International Interdisciplinary Conference on Emergencies, Montreal, Canada. Member Organising Committee Geriatric Component • 2nd November 2005 Visit of Dr George Taler, US National Pressure Ulcer Advisory Panel, to Sydney. • 4th –6th September 2006 Australian Society for Geriatric Medicine Annual Scientific Meeting in Christchurch, Member – Organising Committee • 14 th -15 th Nov 2006 Visit of Professor Ed Ratner, President American Association of Homecare Physicians to Sydney. • 30 th Aug- 2nd Sept 2007 Visit of Professor Shaun O’Keefe to Sydney. • 25 th -26 th Oct 2007 CAPAC and HITH 2007: Moving Forward Conference, Sydney. Member Organising Committee. • 7th Nov 2008, 1 st Annual Scientific Meeting of Hospital in the Home Society of Australasia: Substitution Revolution, Sydney, Member Organising Committee • 5th -6th Nov 2009, 2 nd Annual Conference of the Hospital in the Home Society of Australasia, Sydney, Member Organising Committee.
SUNDRY ACTIVITIES • Convenor: UNSW Geriatric Journal Club 1993-2007
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• Organiser: 2 semesters of coursework, Master of Medicine (Geriatrics), UNSW • Director: Sir Moses Montefiore Jewish Home for the Aged, three nursing home and hostel facilities totalling >700 beds, 1994-2009. • Treasurer, Australian Society for Geriatric Medicine - NSW Executive 1996-2008. • Member, Royal Australasian College of Physicians, Clinical Support Systems Project Taskforce and Reference Group, 1999-2001. • Member, Finance & Administration Committee, Australian Society for Geriatric Medicine (since 2006 renamed the Australian and New Zealand Society for Geriatric Medicine) 2002- • CSIRO Hospital Without Walls Expert Advisory Panel 2003-2004 • Member, Federal Council of the Australian and New Zealand Society of Geriatric Medicine 2006-08 • Consultant, Royal College of Physicians London and British Geriatric Society for the development of guidelines on Advance Care Directives 2008 • Founding President, Hospital in the Home Society of Australasia, 2007-. • External expert, Advance Care Planning in dementia systematic review, Newcastle University, England 2009-2010
DEPARTMENT OF HEALTH CONSULTANCIES 1. Member: Commonwealth Department of Health and Family Services Ambulatory Care Reform Program, Convenor of Group to draft guidelines for preadmission and post acute care. 1996. 2. Member, Steering Committee NSW Department of Aging and Disability Action Plan on Dementia 1996-2004. 3. Member, Steering Committee for Australian Resource Centre for Health Innovation (ARCHI), Hunter Area Health Service 1997-99. 4. Member, Steering Committee for Commonwealth Department of Health and Family Services Consultancy to advance Hospital in the Home, 1998- 1999. 5. Member, Steering Committee, Commonwealth Department of Health and Family Services National Demonstration Hospitals Program (NDHP) III 1998-2000. 6. Member, Committee of NSW Department of Health to draft Establishment Guidelines for Hospital in the Home services, 1999-2000. 7. Member, Program and Editorial Review Committee, ARCHI 1999-2002. 8. Member, State Chronic and Complex Care Implementation Group 2000-2003 9. Member, State Models of Care Implementation Group 2001-2003 10. Member, Australian Health Ministers Advisory Council (AHMAC), originally the Care of Older Australians Working Group (COAWG), now the Health Care of Older Australians Working Group (HCOAWG), Clinical Reference Group (CRG) 2001-. 11. Member, NSW Health Community Acute and Post Acute Care (CAPAC) Steering Committee, and Chairman, CAPAC Forum 2002- 12. Member, Working Group on the Care of Older People in the NSW Health Care System 2002-2003 13. Member, NSW Health Advance Directives Working Party, then Steering Committee, then Advisory Group 2003-. 14. Member, NSW Health Chronic Aged and Community Health Priority Taskforce 2005-. 15. Member, Aged Care Assessment Program, Expert Clinical Reference Group (ECRG) 2009-
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Products and publications arising from the above consultancies Consultancy to advance Hospital in the Home. CHERE. Consultancy to progress Hospital in the Home care provision: Final report. Commonwealth of Australia 1999. ISBN 0 642 41558 7. NSW Action Plan on Dementia 1. SPRC. Carers’ support needs project: promoting the appropriate use of services by carers of people with dementia. Dementia carers and the non-use of community services. Report on the literature review. September 1997. NSW Ageing and Disability Department. 2. Shanley C. Getting in touch: a carer support model using teleconferencing. NSW Ageing and Disability Department, Sydney 2001. ISBN 0 7313 9831 9. 3. Achievements under the NSW Action Plan on Dementia 1996-2001. Department of Ageing, Disability and Home Care, Sydney 2002. ISBN 0 7313 9843 2. 4. Better building better care: A planning guide to improving an aged care facility for people with dementia. Ageing and Disability Department. Sydney June 2000. ISBN 0 7313 9821 1. 5. At home with dementia. Ageing and Disability Department. Sydney March 2000. ISBN 0 7313 9808 4. 6. Promoting flexible respite care for people living with dementia: an information and resource package. NSW Department of Ageing, Disability and Home Care, Sydney 2001. ISBN 0 7313 9839 4. 7. Future Directions for Dementia Care and Support in NSW 2001-2006.NSW Department of Ageing, Disability and Home Care. ISBN 0 7313 9839 4. 2002 8. Fleming R Forbes I Bennett K. Adapting the ward for people with dementia. NSW Health, Sydney 2003. ISBN 0-9580222-5-9. 9. General Practice Dementia Projects funded under the NSW Action Plan on Dementia 1996-2001. NSW Department of Health. ISBN 0 7347 3602 9.
Chronic and Complex Care Implementation Group 1. NSW Clinical Service Framework for Chronic Respiratory Disease – Volume 1. NSW Government Action Plan. NSW Health Sydney 2003. ISBN 0 7347 3447 6. 2. A practical guide for the optimal treatment of chronic respiratory disease – Volume 2, NSW Government Action Plan. NSW Health Sydney 2003. ISBN 0 7347 3448 4. 3. NSW Clinical Service Framework for Heart Failure: overview of the framework and its standards – Volume 1. NSW Health Sydney 2003. ISBN 0 7347 3578 2. 4. NSW Clinical Service Framework for Heart Failure: A practice guide for the prevention, diagnosis and management of Heart Failure in NSW – Volume 2. NSW Health Sydney 2003. ISBN 0 7347 3579 0. 5. NSW Chronic and Complex Care Programs. Progress Report for program activity to 30 September 2002. NSW Health 2003. ISBN 0 7347 3555 3. 6. NSW Health, 2004. NSW Chronic Care Program 2000-2003: Strengthening capacity for chronic care in the NSW health system. Report on phase one. NSW Health, Sydney ISBN 0 7347 3629 0. 7. NSW Health 2005. NSW Chronic Care Program Phase Two 2003-2006. NSW Health, Sydney ISBN: 0 7347 3710 6
Working Group on the Care of Older People Framework for integrated support and management of older people in the NSW health care system 2004-2006. NSW Health Sydney 2004. ISBN 0 7347 3661 4.
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Advance Care Directives Working Party Using Advance Care Directives (NSW). NSW Health Sydney 2004. ISBN 0 7347 3675 4.
AHMAC COAWG CRG 1. Aged Care Evaluation and Management Advisors. AHMAC Working Group on the Care of Older Australians: Examination of length of stay for Older Persons in acute care and sub- acute sectors. 2003 Available at www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-minconf.htm 2. Howe AL, Rosewarne R, Opie J. Stocktake of models of care at the Acute-Aged Care Interface. 2002. Available at www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-minconf.htm 3. National Ageing Research Institute and Centre for Applied Gerontology. Service provision for older people in the Acute-Aged Care system: Final Report 2002. Available at www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-minconf.htm 4. AIHW. Feasibility study on linking hospital morbidity and residential aged care data to examine the interface between the two sectors. 2002. Available at www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-minconf.htm 5. University of South Australia. Review of assessment and transition practices for older people in acute public hospitals, 2003. Available at www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-minconf.htm 6. Siggins Miller. Unnecessary and avoidable hospital admissions for older people. 2003. 7. From hospital to home: improving care outcomes for older people. A National Action Plan for improving care of older people across the acute-aged care continuum, 2004-2008. Department of Human Services, Melbourne on behalf of AHMAC. ISBN 07 3116 2528. Available at www.health.vic.gov.au/acute-agedcare 8. Clinical Epidemiology & Health Service Evaluation Unit. Best practice approaches to minimise functional decline in the older person across the acute, subacute and residential aged care settings. Department of Human Services, Melbourne. ISBN 07 3116 2196. Available at www.health.vic.gov.au/acute-agedcare 9. Clinical Epidemiology & Health Service Evaluation Unit. A guide for assessing older people in hospitals. Department of Human Services, Melbourne. ISBN 07 3116 2188. Available at www.health.vic.gov.au/acute-agedcare 10. Clinical Epidemiology & Health Service Evaluation Unit. Clinical Practice Guidelines for the Management of Delirium in Older People. Victorian Department of Human Services, Melbourne 2006. ISBN 0731162757. Available at www.health.vic.gov.au/acute-agedcare 11. Sansoni J, Marosszeky N, Fleming G and Sansoni E (2010) Selecting Tools for ACAT Assessment: A Report for the Aged Care Assessment Program (ACAP) Expert Clinical Reference Group. Centre for Health Service Development, University of Wollongong. Report for the Aged Care Assessment Program, Australian Government Department of Health and Ageing,
Canberra 29 July, 2010
In publication 1. National Stroke Foundation. Stroke Care Pathway. 2. National Framework on the Care of Older People Across the Acute-Aged Care Continuum – developed in conjunction with the Care of Older Australians Working Group. This aims to ensure adequate and equitable distribution of services for older Australians across all jurisdictions. The framework contains guiding principles which lead to major issues and then goals with specified key responsible stakeholders (namely
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which level of government is responsible) and what their level of commitment should be, with specified actions and compliance measures to determine progress. The framework emphasises the importance of developing and retaining a skilled workforce to enable access to medical care and services.
National Demonstration Hospitals Program (NDHP) My role in the three phases of NDHP with which I was involved, was to act as a consultant to other hospitals to assist them to develop and deploy the same services that I was running at Prince of Wales Hospital. The hospitals that I assisted in this way were NDHP I 1. Sir Charles Gairdner Hospital, Perth 2. Sale Hospital, Gippsland Victoria 3. Ballarat Base Hospital, Victoria 4. North West Hospital, Melbourne 5. Princess Alexandra Hospital Brisbane 6. Queen Elizabeth II Hospital, Brisbane 7. Mackay Base Hospital, Queensland NDHP III 8. Ipswich Hospital, Queensland 9. Newcastle Mater Misericordiae Hospital, NSW 10. Alice Springs Hospital, Northern Territory 11. North West Regional Hospital, Burnie, Tasmania 12. Rockhampton District Health Services NDHP IV 13. Austin and Repatriation Medical Centre, Melbourne, Victoria 14. Bairnsdale Regional Health Service, Victoria 15. Central Coast Health Service, NSW 16. Maitland Hospital, NSW 17. Toowoomba Health Service, Queensland
Under the NSW Rural Hospital in the Home (HITH) scheme 1996-97 five NSW rural hospitals were mentored to establish HITH services.
Non-government consultancies CSIRO’s Hospital Without Walls Expert Advisory Panel 2003-2004 to assist the CSIRO in their development of technology for health and aged care at home.
MEDICAL JOURNALS, etc Member Editorial Board, Journal of Gerontology: Medical Sciences , 1999-2004. Member Editorial Board, Journal of the American Medical Directors Association 2006- Member Editorial Board, The Open Geriatric Medicine Journal 2007- Member Advisory Board, Australian Doctor 2008-9 Member, Editorial Board, Current Gerontology and Geriatrics Research 2010- Reviewer, Medical Journal of Australia , 1999-2007 Reviewer, Preventative Medicine , 2000 Reviewer, Circulation , 2000 Reviewer, Journal of Gerontology: Medical Sciences 2000-2004 Reviewer, Biomed Central: Health Service Research 2003-7, 2009 Reviewer, Internal Medicine Journal 2004-9 Reviewer, Australian Health Review 2004 Reviewer, Health Policy 2005
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Reviewer, Biomed Central: Geriatrics 2005 Reviewer, Canadian Medical Association Journal 2005-7 Reviewer, Canadian Journal on Aging 2005-6 Reviewer, Biomed Central Public Health 2006 Reviewer, JAMDA 2006-2010 Reviewer, Archives of Internal Medicine 2007-9 Reviewer, Age and Ageing 2007-8 Reviewer, Respiratory Medicine 2007 Reviewer, Journal of Pharmacy Practice and Research 2008 Reviewer, International Journal of Nursing Studies 2008 Reviewer, Emergency Medicine Australasia 2008 Reviewer, JAMA 2008-10 Reviewer, Journal of the American Geriatrics Society 2009 Reviewer, JNHA 2009 Reviewer, BMJ 2009-10 Reviewer, European Journal of Cancer 2010 Reviewer, Dementia: The International Journal of Social Research and Practice 2010
GRANT REVIEWS NH&MRC 1999, 2001, 2003-5, 2010 Alzheimers Australia 2005 Research into Aging (UK), 2006 Health Research Board, Ireland 2007 Health Services Research Committee of Scotland, 2009 Singapore Ministry of Health, 2009
GENERAL MEDIA 27/12/1989 Medical mayhem Illawarra Mercury p1. 13/2/1994 Tending an aging population The Sun Herald p 14. 6/5/1997 Hospital care based at home. The Southern Courier . 1/8/1998 Interview, Newcastle 2NC . 7/9/1998 Hospital study supports shorter stays. The Age , p 4. 7/9/1998 Staying in hospital a health hazard. The Sydney Morning Herald , p 3. 7/9/1998 Interview with James Valentine, Sydney 2BL . 7/9/1998 Interview, Newcastle 2NC 7/9/1998 Interview, Suzanne Gibson, Darwin 8DDD . 8/9/1998 Interview Caroline Alton, London BBC World Service . 8/9/1998 Interview John Hancock Adelaide 5AAA . 18/9/1998 Shorter stay reduces infection. Australian Doctor, p 7 . 26/2/1999 Study backs hospital in the home for aged. Australian Doctor, p.4. 18/3/1999 Quicker, cheaper and safer. Sydney Morning Herald, p.11. 26/3/1999 GPs to care for acute patients at home. Australian Doctor p.22. Healthcare’s homecoming. Australian Health & Aged Care Journal, 1999;10 (4); 26-29. 6/5/1999 Hospital in the Home, Channel Seven News 7/5/1999 Interview with ABC radio Lismore. 1/6/1999 Hospital beds traded for home treatment. Southern Courier p.11. 4/1/2000 Patient care in the home. Southern Courier p.9. 26/5/2000 Home hospitals a healthier option. The Daily Telegraph p.13. 26/5/2000 News item/interview. Sydney 2GB and 2CH.
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26/5/2000 Interview. Prue McSween Sydney 2UE. 27/5/2000 Interview. Luke Bona Sydney 2GB. 20/4/2001 Interview – diet and ageing. Today Tonight Channel 7 . 12/2/2002. LMWH at home. Channel 9 News 12/2/2002 Interview with Ernie Sigley. 3AW 12/2/2002 Interview, 2SM . 18/7/2004 Sunday program. Dying by inches. Channel 9 . 21/12/2004 Interview. Tim Webster Sydney 2GB. 21/12/2004 Interview. Luke Bona Sydney 2GB. 21/12/2004 Interview. ABC News . 22/4/2005 Montefiore board member made A/Prof. The Australian Jewish News p. 2 29/6/2006 Be it ever so humble, there’s no place like home. The Australian Financial Review , p.59. 26/7/2006 Planning improves life for nursing home residents. The Southern Courier . 03/8/2006 Interview with Richard Aedy re Advance Care Directives – Life Matters. Radio National 06/8/2006 “Casualty ward coming to a lounge room near you” The Sun Herald p. 7 20/8/2006 Interview with Glenn Wheeler Sydney 2UE. 09/9/2006 Jewish leader was the man to have in a crisis. Sydney Morning Herald p. 51 22/10/2006 “Plagued by memories” Compass. ABC TV 04/11/2006 “No place like home” The Age 09/5/2007 Malnutrition in older hospital patients. Channel 9 News. 04/6/2007 Self-rated health Nova96.9 04/6/2007 Self-rated health ABC Radio Central Coast + Newcastle 04/6/2007 Self-rated health Private Hospitals Journal 27/3/2008 Shortages an old-age story Australian Doctor 24/9/2008 HITH Auditor General Report – News Channel 9 24/9/2008 HITH Auditor General Report – News Channel 7 22/10/2008 Interview with Tim Webster Radio 2UE 16/09/2010 Breakthrough in delirium research -News ABC TV 16/09/2010 Delirium linked to dementia – smh.com.au 16/09/2010 Delirium linked to dementia – ninemsn.com.au 28/09/2010 Dementia search breakthrough – Southern Courier
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