Sharma Y, Mangoni AA, Horwood C
… +1 more, Thompson C
Aust Health Rev
· 2024 Dec · PMID 39218620
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Objective Community-acquired pneumonia (CAP) is a leading cause of emergency hospitalisations globally and is associated with high readmission rates. Specific score systems developed for all medical conditions such as th...Objective Community-acquired pneumonia (CAP) is a leading cause of emergency hospitalisations globally and is associated with high readmission rates. Specific score systems developed for all medical conditions such as the HOSPITAL score and the LACE index can also usefully predict CAP readmissions. However, there is limited evidence regarding their performance in the Australian healthcare settings. Methods This multicentre retrospective study analysed adult CAP discharges from two metropolitan hospitals in South Australia between 1 January 2018 and 31 December 2023. Data for determining the HOSPITAL score and the LACE index were derived from electronic medical records. Demographic characteristics of patients readmitted within 30 days were compared with those who were not readmitted. The scores were evaluated for overall performance, discriminatory power and calibration, with discriminatory power assessed using the concordance statistic (C-statistic). Results Over 6years, 7245 CAP discharges were recorded, with 1329 (18.3%) readmissions within 30days. The mean (s.d.) age of the cohort was 74.4 (17.8) years. Readmitted patients were more likely to have multiple morbidities and frailty than those not readmitted (P <0.05). They also had a higher mean number of emergency department presentations and hospital admissions in the previous year and a longer initial hospital stay (P <0.05). Overall, the mean (s.d.) HOSPITAL score and LACE index were 3.4 (2.1) and 9.3 (3.6), respectively. Among readmissions, 28.4% occurred in patients with a HOSPITAL score >4 (intermediate and high-risk group), while 25.8% occurred in patients in the high-risk LACE category (LACE index>10). The C-statistic for the HOSPITAL score and LACE index was 0.62 (95% CI 0.61-0.64) and 0.63 (95% CI 0.61-0.65), respectively, with no significant difference in the area under the receiver operating characteristic curves (P >0.05). Conclusions The predictive abilities of the HOSPITAL score and the LACE index for CAP readmissions are modest and comparable in an Australian setting.
Harper K, Williamson M, Arendts G
… +7 more, Edwards D, Buller B, Haak J, Jacques A, Barton A, Petta A, Celenza A
Aust Health Rev
· 2024 Aug · PMID 39183070
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Objective Patient engagement, as measured by the Patient Activation Measure (PAM® ), has been used to assess patients' ability to manage their own care. This study aimed to determine whether the PAM® could predict health...Objective Patient engagement, as measured by the Patient Activation Measure (PAM® ), has been used to assess patients' ability to manage their own care. This study aimed to determine whether the PAM® could predict healthcare use in older adults aged >70years, living independently in the community with mild frailty, within 30days after emergency department (ED) discharge. Methods A prospective single-centre observational cohort study was completed including older adults who presented to an ED. The 13-item PAM® and selected International Consortium for Health Outcomes Measures were completed prior to ED discharge. Results Two hundred patients were recruited with a mean age of 84.8years (s.d. 6.9). The mean PAM® score was 58.6 (s.d. 13.3), with 12.5% at Level 1 (n =25), 40% at Level 2 (n =80), 34.5% at Level 3 (n =69) and 13.0% at Level 4 (n =26). The PAM® level was significantly associated with ED presentations in the past 6months (P =0.030). The PAM® level did not predict healthcare use within 30days of discharge consisting of time until ED representation (P =0.557), number of ED representations (P =0.560), number of hospital admissions (P =0.499), length of stay in hospital (P =0.254) and number of post-discharge contacts (P =0.667). Conclusions Overall, the PAM® did not predict prospective short-term healthcare use. However, the PAM® was significantly associated with 6-month previous ED use. With more than 50% of patients at Level 1 or 2, indicating lower capacity for self-management, tailored interventions are required to assist mildly frail patients to manage discharge care plans and engage in preventative strategies.
McFadden K, Rickard CM, Brown C
… +4 more, Corley A, Schults JA, Craswell A, Byrnes J
Aust Health Rev
· 2024 Oct · PMID 39183067
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Peripheral intravenous catheters (PIVCs) are required by most hospitalised patients. Difficult intravenous access (DIVA) makes insertion challenging, with poor patient outcomes, treatment delays and resource waste from m...Peripheral intravenous catheters (PIVCs) are required by most hospitalised patients. Difficult intravenous access (DIVA) makes insertion challenging, with poor patient outcomes, treatment delays and resource waste from multiple insertion attempts, often by multiple clinicians. This exploratory qualitative case study aimed to investigate how clinical and executive hospital staff view PIVC insertions for patients with DIVA from a cost and efficiency perspective. Fifteen semi-structured interviews were conducted with staff from three large, urban Australian hospitals. Data was thematically analysed, with four themes generated: (1) PIVCs are not considered from a cost or resource use perspective; (2) resources required for successful PIVC insertion are variable and unpredictable; (3) limited funding and support exist for advanced skill and ultrasound-guided insertion; and (4) processes for PIVC training and competency are inefficient. Investment in advanced PIVC inserters (with ultrasound-guided cannulation skills, and ability to train and assess novice inserters), with clear escalation pathways to these clinicians may reduce inefficiencies and waste associated with difficult PIVC insertions.
Aust Health Rev
· 2024 Oct · PMID 39183064
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OBJECTIVE: To evaluate how surgeons in Australia and Aotearoa New Zealand perceive the effectiveness of the Operating with Respect (OWR) face-to-face training program in reducing workplace bullying. METHODS: A cross-sect...OBJECTIVE: To evaluate how surgeons in Australia and Aotearoa New Zealand perceive the effectiveness of the Operating with Respect (OWR) face-to-face training program in reducing workplace bullying. METHODS: A cross-sectional survey examined the perceived effectiveness of the Royal College of Surgeons' (RACS) face-to-face OWR training and complementary interventions in reducing workplace bullying in surgical settings. The sample included supervisory surgeons, RACS committee members, and targeted educators. The survey instrument had 35 questions, including five related to the research question. In December 2020, the survey was distributed by RACS to all surgeons who undertook OWR training between April 2017 and December 2019. Likert scales and coded free text responses were used to explore the effectiveness of face-to-face OWR training and other interventions included in the 2015 RACS Action Plan. RESULTS: Of the 756 surveys sent, 252 were received. The face-to-face OWR training program was rated as moderately effective. RACS's overarching approach to anti-bullying was almost equally important, highlighting the need to consider a broader ecosystem of reform. CONCLUSIONS: This study finds the RACS full-day anti-bullying training moderately effective in reducing bullying in surgical workplaces. However, enhancing its impact requires a sustained, multi-faceted strategy, including broader policy reforms, accountability measures, and cultural changes, to foster a long-term respectful environment in surgical settings.
Cortie CH, Garne D, Parker-Newlyn L
… +4 more, Ivers RG, Mullan J, Mansfield KJ, Bonney A
Aust Health Rev
· 2024 Oct · PMID 39183063
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OBJECTIVE: This study aimed to examine changes in the demographics and regions of work of Australian doctors over a period of 9 years. METHODS: A retrospective study of Australian Health Practitioner Regulation Agency (A...OBJECTIVE: This study aimed to examine changes in the demographics and regions of work of Australian doctors over a period of 9 years. METHODS: A retrospective study of Australian Health Practitioner Regulation Agency (AHPRA) registration data was performed. Data were sourced from the Health Workforce Dataset Online Data Tool which was derived from annual registration data from AHPRA for 2013-2022. The demographic factors analysed were gender, age, and origin of qualification. Regions of work were defined using the Modified Monash (MM) model. RESULTS: The number of registered doctors increased from 82,408 in 2013 to 111,908 in 2022 but mean hours worked per week decreased from 41 to 39 leading up to 2020. Trends in age and origin of qualification remained stable, but the proportion of female workers increased from 38.5% in 2013 to 44.5% in 2022. While female hours per week (~37) were consistent from 2013 to 2020, male hours per week decreased from 43 to 41. The number of registrations and total full-time equivalent (FTE) outcomes increased consistently in metropolitan (MM1) and rural (MM2-5) regions but did not increase for remote and very remote (MM6-7) regions. CONCLUSION: The Australian medical workforce both grew and changed between 2013 and 2022. An overall decrease in mean hours worked appears to be driven by a decline in hours worked by male workers and the increased proportion of female workers. While increased gender parity and a decrease in hours worked per week were positive outcomes, a lack of growth in the medical workforce was noted in remote and very remote regions of Australia.
Ryan L, Hattingh L, Carlini J
… +9 more, Weir KA, Shapiro M, Baglot N, Cardona M, Tobiano G, Muir R, Roberts S, Sargeant S, Wenke R
Aust Health Rev
· 2024 Aug · PMID 39183053
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Objective Consumer involvement is when patients (their families, friends, and caregivers) work with researchers on research projects. While health services are expected to support consumer-researcher collaborations, cond...Objective Consumer involvement is when patients (their families, friends, and caregivers) work with researchers on research projects. While health services are expected to support consumer-researcher collaborations, conducive environments still need to be developed, with limited research into how Australian health services support this practice. This study explores current consumer involvement in research activity and staff perceptions at an Australian tertiary hospital and health service. Methods Research-active employees at a health service were invited to participate in an online cross-sectional survey. It assessed experience with and confidence in involving consumers in research, the perceived value of consumer involvement, and considerations related to challenges, facilitators, and solutions to enhance consumer involvement in health service research. Results Among 83 respondents, including medical, nursing, and allied health professionals, 54 completed the survey. Approximately half had experience with involving consumers in research. Over 80% recognised that involving consumers enhanced research relevance. Identified barriers included challenges in finding (46.6%) and compensating (59.3%) consumers, as well as deficiencies in researcher skills, knowledge (32.2%), and time constraints (39%). Facilitators comprised access to experienced researchers and educational opportunities. Moreover, 87% advocated for increased support to involve consumers within health services, with the appointment of a designated consumer involvement officer deemed the most beneficial solution by 92.5% of respondents. Conclusions While individual barriers inhibit consumer involvement in research, more prominent institutional factors such as financial and technical support may determine successful and meaningful collaborations. As health services evolve towards co-design models in research, the outcomes of this study will guide initiatives aimed at enhancing consumer involvement in the research process within Australian health services.
Aust Health Rev
· 2024 Oct · PMID 39155064
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OBJECTIVE: Hospital chief executive officers (CEOs) in Australia encounter various challenges such as financial constraints, changing regulations, and the necessity to uphold patient care standards. These challenges can...OBJECTIVE: Hospital chief executive officers (CEOs) in Australia encounter various challenges such as financial constraints, changing regulations, and the necessity to uphold patient care standards. These challenges can contribute to rates of CEO turnover, which can disrupt healthcare organisations and affect the quality of services provided. This research aims to pinpoint the factors influencing hospital CEO turnover and explore effective strategies for retaining these vital leaders. METHODS: A survey was carried out among hospital CEOs throughout Australia. The survey, distributed through email and online platforms, gathered information on reasons behind turnover and methods for retaining CEOs. Data from 51 CEOs were analysed using statistical regression techniques and thematic analysis. RESULTS: The findings from the survey indicated that 82.35% of CEOs identified stress and work-related pressure as the causes of turnover. Other significant factors included managing under-resourced organisations (68.62%), lack of support from the board (66.66%), and facing internal/external criticisms (58.82%). On average, respondents reported 5.16 reasons for leaving their positions with no significant differences found based on sociodemographic characteristics. It was pointed out that key ways to retain CEOs include building respect and trust between CEOs and board chairs, meeting the training and development needs of CEOs, and defining roles within the organisation. The importance of succession planning was also emphasised, with 94.12% of respondents acknowledging its significance for maintaining stability. CONCLUSION: The study underscores the multifaceted nature of CEO turnover in Australian hospitals influenced by organisational dynamics, performance factors, and personal elements. Effective retention strategies necessitate a culture within the organisation, defined roles, sufficient resources, and robust succession planning. Addressing these aspects can bolster leadership continuity and enhance the performance of healthcare organisations.
Triandafilidis Z, Goodwin N, Hutchinson K
… +6 more, Jeong SY, Lewis S, Hodyl N, Quick G, Hensby J, Montague A
Aust Health Rev
· 2024 Aug · PMID 39143007
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A need exists to improve end-of-life care for people with advanced dementia, by integrating available services. Stakeholders on the Central Coast of New South Wales united to co-design an improved model of care that woul...A need exists to improve end-of-life care for people with advanced dementia, by integrating available services. Stakeholders on the Central Coast of New South Wales united to co-design an improved model of care that would integrate care across care settings. The aim of this project was to co-design a model of integrated, person-centred palliative care for people with dementia at the end of life. This case study describes seven co-design workshops which took place in 2023 to develop a program logic model. Workshops were run in a hybrid format, with stakeholders attending in person and online. Workshops were attended by an average of 26 stakeholders including people and carers with lived experience of dementia, healthcare workers from hospital and community-based services (public and private), primary care clinicians, and participants from the not-for-profit sector and academia. Stakeholders developed a shared mission and purpose and identified priority areas for improving palliative care for people with advanced dementia. This led to the development of a program logic model, which included components relating to education for people with dementia, carers, and professionals, care coordination and referrals, and regular multidisciplinary case conferences. Feedback on the model from a new audience identified areas for improvement. The stakeholder group participated in a survey to evaluate the effectiveness of the co-design. The survey found that stakeholders were satisfied with the model of care the group developed. This project highlighted the value of adopting a co-design approach with stakeholders to develop a new model of care.
Grove K, Cavalheri V, Chih H
… +26 more, Natarajan V, Harrold M, Mohd S, Hurn E, Van der Lee L, Maiorana A, Tearne J, Watson C, Pearce J, Jacques A, White A, Vicary C, Roffman C, Synnott EL, Suttie I, Lin I, Larsson J, Naylor L, Woodhouse L, Elliott M, Gittings P, Winship P, Timms R, Wulff S, Hebden-Todd T, Edgar DW
Aust Health Rev
· 2024 Oct · PMID 39111822
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OBJECTIVE: This study aimed to compare the relative physical recovery and symptoms after SARS-CoV-2 infection between groups confirmed positive or negative to early strains of COVID-19. METHODS: A prospective, longitudin...OBJECTIVE: This study aimed to compare the relative physical recovery and symptoms after SARS-CoV-2 infection between groups confirmed positive or negative to early strains of COVID-19. METHODS: A prospective, longitudinal cohort study compared outcomes of metropolitan adults polymerase chain reaction-tested for COVID-19 between March and November 2020 in Western Australia. Control matching was attempted: inpatients (gender, age) and ambulatory clinic (gender, age, asthma, chronic pulmonary disease). One-year follow-up involved three repeated measures: physical function (grip strength and 1-min sit-to-stand) and patient-reported outcomes (Fatigue Severity Scale, modified Medical Research Council dyspnoea scale and Euroqol-5D-5L). RESULTS: Three hundred and forty-four participants were recruited (154 COVID+, age 54 ± 18 years, 75 females [49%]); 190 COVID-, age 52 ± 16 years, 67 females [35%]) prior to national vaccination roll-out. No between-group differences in physical function measures were evident at any time point. Fatigue (OR 6.62, 95% CI 2.74-15.97) and dyspnoea (OR 2.21, 95% CI 1.14-4.30) were higher in the COVID+ group at second assessment (T2). On Euroqol-5D-5L, no between-group differences were evident in the physical function domains of self-care, mobility or usual activities at any time point. However, COVID+ participants were less likely to report an absence of anxiety or depression symptoms at T2 (OR 0.41, 95% CI 0.19-0.89). CONCLUSIONS: Neither statistical nor clinically meaningful differences in physical function were evident between COVID+ and COVID- participants to 12-months after acute illness. Symptoms of fatigue, dyspnoea, anxiety or depression were more prevalent in the COVID+ group til ~8 months after illness with between-group differences no longer evident at 1 year.
Aust Health Rev
· 2024 Oct · PMID 39103229
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OBJECTIVE: To provide the first document map of sustainability and decarbonisation actions across the Australian healthcare sector, as reported in publicly available documents online, and to identify gaps in actions. MET...OBJECTIVE: To provide the first document map of sustainability and decarbonisation actions across the Australian healthcare sector, as reported in publicly available documents online, and to identify gaps in actions. METHODS: Healthcare providers were identified across all state and territories. Structured Google searches between August and December 2022 were followed by document searches. Updates were undertaken, most recently in December 2023. Targeted documents included position statements, strategies, and reports. Key points from these documents pertaining to sustainability and/or decarbonisation were extracted and descriptively analysed. RESULTS: A total of 294 documents were included, mostly focused on power generation, transport, building design, and circular procurement/waste pathways. In contrast, relatively few plans for decarbonisation of clinical care were identified (n = 42). National and two state governments (New South Wales, Western Australia) have established healthcare sustainability and decarbonisation units, and two further states have publicly committed to doing so (Queensland, Tasmania). However, these documents generally reported separate, siloed actions. While attempts were made to make this review comprehensive, some documents may have been missed or are only available inside an organisation, and new actions will continue to emerge. CONCLUSION: Broad sustainability plans have been developed by many healthcare providers; however, to achieve net zero, decarbonising of clinical practices is also needed, and this is where the least action is currently occurring. To decarbonise clinical care, the sector needs to come together in a more coordinated way.
Aust Health Rev
· 2024 Aug · PMID 39088380
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What is known about the topic? Sonographers are well-known for their diagnostic roles in medical ultrasound though many have significant exposure to a range of interventional procedures. What does this paper add? Some s...What is known about the topic? Sonographers are well-known for their diagnostic roles in medical ultrasound though many have significant exposure to a range of interventional procedures. What does this paper add? Some sonographers are trained and qualified in these, including performing ultrasound-guided musculoskeletal injections. What are the implications for practitioners? A number of barriers exist for sonographers to use these skills to potential within the Australian healthcare system.
Aust Health Rev
· 2024 Aug · PMID 39088379
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What is known about the topic? The health workforce and health tasks are highly contested and largely controlled by regulation. Since the introduction of medical regulation in the mid-19th century, the practice of surge...What is known about the topic? The health workforce and health tasks are highly contested and largely controlled by regulation. Since the introduction of medical regulation in the mid-19th century, the practice of surgery has been largely dominated by medically trained surgeons. A small group of Australian podiatrists have defied these historic boundaries by creating their own colleges of training and convincing government and regulators of their safety and efficacy in surgical practice. The Podiatry Board of Australia commissioned an independent review of the regulation and regulatory practices of podiatric surgeons in Australia. What does this paper add? This paper discusses the implications of a regulatory review of the role of podiatric surgeons for professional role boundaries. What are the implications for practitioners? Despite historic role boundaries and definitions, with appropriate training, regulation, and financing, the health workforce can be mobilised in different ways to meet population needs, overcoming a professional monopoly over roles.
Aust Health Rev
· 2024 Aug · PMID 39088378
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Publisher ↗
The role of radiographers in healthcare has evolved significantly from operating imaging equipment to being essential in patient care and diagnosis. In Australia, radiographers play a crucial role in image interpretation...The role of radiographers in healthcare has evolved significantly from operating imaging equipment to being essential in patient care and diagnosis. In Australia, radiographers play a crucial role in image interpretation, identifying and communicating significant findings to enhance patient outcomes. Preliminary image evaluation (PIE) allows radiographers to interpret images and ensure significant findings are noted, particularly in urgent situations, complementing diagnoses when radiologist reports are unavailable. Despite their potential, many radiographers lack empowerment, leading to delays and adverse patient outcomes. This underutilisation stems from a lack of support and systemic barriers. Radiographers, with their extensive expertise in imaging, are vital for ensuring patient safety and care quality. Policy changes are needed to integrate PIE into standard workflows, allowing radiographers to fully utilise their skills. Recognising and leveraging their expertise will enhance patient care, foster collaboration, and ensure radiographers contribute fully to the healthcare team, ultimately improving patient safety and care quality.
Cheung W, Naganathan V, Myburgh J
… +21 more, Saxena MK, Blyth F, Seppelt I, Parr M, Hooker C, Kerridge I, Nguyen N, Kelly S, Skowronski G, Hammond N, Attokaran A, Chalmers D, Gandhi K, Kol M, McGuinness S, Nair P, Nayyar V, Orford N, Parke R, Shah A, Wagh A
Aust Health Rev
· 2024 Aug · PMID 39088377
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Publisher ↗
Aust Health Rev
· 2024 Aug · PMID 39084231
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Publisher ↗
What is known about the topic? Little is known about the state of mental health reform in Australia. This article describes the struggle to develop the systems of accountability necessary to assess national progress. Wha...What is known about the topic? Little is known about the state of mental health reform in Australia. This article describes the struggle to develop the systems of accountability necessary to assess national progress. What does this paper add? We provide some historical context regarding mental health reform and consider recent efforts in particular, before then describing current key opportunities. What are the implications for practitioners? Many people working in mental health are struggling to deliver quality services to Australians. This paper considers the broad policy issues which have led to this situation. This is useful for practitioners who can then better respond and participate in processes of systemic reform. Opportunities to engage now in key policy formulation are identified in the article.
Aust Health Rev
· 2024 Oct · PMID 39074843
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Publisher ↗
OBJECTIVES: This study aimed to determine the feasibility of capturing antimicrobial usage data from prisons for inclusion in the Antimicrobial Use and Resistance in Australia (AURA) surveillance system and to analyse 20...OBJECTIVES: This study aimed to determine the feasibility of capturing antimicrobial usage data from prisons for inclusion in the Antimicrobial Use and Resistance in Australia (AURA) surveillance system and to analyse 2021 and 2022 South Australian (SA) usage data for notable trends. METHODS: Monthly antimicrobial supply data for eight SA prisons were collected. Antimicrobial volume was converted into the World Health Organization metric, defined daily doses (DDD). Usage rates were calculated relative to prison occupied bed days (OBD). RESULTS: Annual usage of systemic antimicrobials across eight SA prisons totalled 26,448 DDD and 23,526 DDD in 2021 and 2022 respectively. Antibacterials accounted for 80.6% of all antimicrobials dispensed during the study period. The average antibacterial usage rate in female prisons was higher on average than in male prisons. The state-wide systemic antibacterial usage rate in SA prisons declined by 11.3% from 23.8 DDDs/1000 OBD in 2021 to 21.1 DDDs/1000 OBD. Doxycycline, amoxicillin, flucloxacillin, amoxicillin-clavulanic acid, and cefalexin accounted for 72% of the total systemic antibacterial usage rate. Variation in the oral and topical antifungal agents used and the rate of use was observed between prisons. CONCLUSIONS: This SA pilot study demonstrates the feasibility of including prisons in routine national antimicrobial surveillance using similar methodology to hospital surveillance. The contributing facilities comprised 6.1% of all Australian prison beds, and extrapolation of the results suggests that the identified gap in surveillance may equate to over 400,000 DDD per annum in prisons nationwide, equating to approximately 5% of hospital inpatient antimicrobial usage.
Schultz TJ, Oster C, Pincombe A
… +7 more, Partington A, Taylor A, Gray J, Murray A, McInnes J, Ryan C, Karnon J
Aust Health Rev
· 2024 Jul · PMID 39074838
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Publisher ↗
Objectives This study aimed to compare clinical outcomes for patients admitted to Hospital in the Home (HITH) and traditional (bricks-and-mortar) hospitals and explore patient and carer experiences. Methods A mixed metho...Objectives This study aimed to compare clinical outcomes for patients admitted to Hospital in the Home (HITH) and traditional (bricks-and-mortar) hospitals and explore patient and carer experiences. Methods A mixed methods approach including triangulation of quantitative and qualitative data was used. Quantitative outcomes were compared using augmented inverse propensity weighting to adjust for differences in patient characteristics between groups. Qualitative data was collected by focus groups and interviews and analysed using reflexive thematic analysis. The study took place in metropolitan Adelaide and one adjacent regional health network in 2020-22. Participants were patients discharged from either hospital setting with 1 of 22 eligible diagnoses. Hospital administrative data informed a comparison of outcomes that included mortality, rate of emergency department re-presentations and re-admissions, length of stay and incidence of complications. Results Patients treated in HITH were less unwell than traditional hospital patients. There were no safety or quality concerns identified in the clinical outcomes. Of 2095 HITH patients, the in-patient mortality rate was 0.2%, and 2.3% experienced a return to a bricks-and-mortar hospital during the HITH admission. For HITH patients, the mortality rate after 30days was lower (-1.3%, 95% CI -2 to -0.5, P =0.002), as were re-presentations in 28days (-7.2%, 95% CI -9.5 to -5, P <0.0001), re-admissions in 28days (-4.9%, 95% CI -6.7 to -3.2, P <0.001) and complications (-0.6%, 95% CI -0.8 to -0.5, P <0.001). Interviews of 35 patients and six carers found that HITH was highly accepted and preferred by patients. HITH was perceived to free up resources for other, more acutely unwell patients. Conclusions HITH was preferred by patients and at least as effective in delivering quality health care as a traditional hospital, although the potential for unobserved confounding must be acknowledged.