Impact of disinvestment from weekend allied health services across acute medical and surgical wards: 2 stepped-wedge cluster randomised controlled trials

Abstract

BackgroundDisinvestment (removal, reduction, or reallocation) of routinely provided health services can be difficult when there is little published evidence examining whether the services are effective or not. Evidence is required to understand if removing these services produces outcomes that are inferior to keeping such services in place. However, organisational imperatives, such as budget cuts, may force healthcare providers to disinvest from these services before the required evidence becomes available. There are presently no experimental studies examining the effectiveness of allied health services (e.g., physical therapy, occupational therapy, and social work) provided on weekends across acute medical and surgical hospital wards, despite these services being routinely provided internationally. The aim of this study was to understand the impact of removing weekend allied health services from acute medical and surgical wards using a disinvestment-specific non-inferiority research design.Methods and findingsWe conducted 2 stepped-wedge cluster randomised controlled trials between 1 February 2014 and 30 April 2015 among patients on 12 acute medical or surgical hospital wards spread across 2 hospitals. The hospitals involved were 2 metropolitan teaching hospitals in Melbourne, Australia. Data from n = 14,834 patients were collected for inclusion in Trial 1, and n = 12,674 in Trial 2. Trial 1 was a disinvestment-specific non-inferiority stepped-wedge trial where the ‘current’ weekend allied health service was incrementally removed from participating wards each calendar month, in a random order, while Trial 2 used a conventional non-inferiority stepped-wedge design, where a ‘newly developed’ service was incrementally reinstated on the same wards as in Trial 1. Primary outcome measures were patient length of stay (proportion staying longer than expected and mean length of stay), the proportion of patients experiencing any adverse event, and the proportion with an unplanned readmission within 28 days of discharge. The ‘no weekend allied health service’ condition was considered to be not inferior if the 95% CIs of the differences between this condition and the condition with weekend allied health service delivery were below a 2% increase in the proportion of patients who stayed in hospital longer than expected, a 2% increase in the proportion who had an unplanned readmission within 28 days, a 2% increase in the proportion who had any adverse event, and a 1-day increase in the mean length of stay. The current weekend allied health service included physical therapy, occupational therapy, speech therapy, dietetics, social work, and allied health assistant services in line with usual care at the participating sites. The newly developed weekend allied health service allowed managers at each site to reprioritise tasks being performed and the balance of hours provided by each professional group and on which days they were provided. Analyses conducted on an intention-to-treat basis demonstrated that there was no estimated ef...

Translating evidence into practice: A longitudinal qualitative exploration of allied health decision making.

“…Typically, reduced allied health services are available during weekends, with the goal of facilitating patient discharge, and preventing adverse events and escalation of care. Further, there is a variety in weekend allied health provision both within (22) and between health services (20,21). Within services, allied health departments have different levels of availability during weekends based on perceived benefits (23,24).…”

The effect of delegation of therapy to allied health assistants on patient and organisational outcomes: a systematic review and meta-analysis

“…In contrast, the AHA clinical role primarily involves providing therapy [7,32,40]. Given that previous evaluations on increasing allied health services in the acute setting have shown that its effects on patient and organisational outcomes are unclear, future evaluations on additional allied health services may consider the effects of increasing the ratio of AHA to allied health professional staffing [62,63].…”

Implementation of evidence-based weekend service recommendations for allied health managers: a cluster randomised controlled trial protocol

“…The mean hospital length of stay for relevant wards over the 1 month period preceding random group allocation, and the same corresponding month 12 months later. Hospital length of stay is a key driver of hospital efficiency [ 49 – 52 ] and provides a measure of benefit or non-inferiority for weekend allied health provision [ 37 , 38 , 53 ].…”