Business of Oncology
Original Contribution
Workforce Profile for Allied Health Professions in Queensland Public Health Cancer Care Services With Linear Accelerators Department of Health, Queensland Government, Brisbane, Queensland, Australia
Abstract Purpose: This article profiles staffing levels for all allied health professionals in Queensland Public Health cancer care services to determine whether linear accelerator hours per clinical day are a potentially useful predictor of workforce requirements. Currently, radiation therapists and radiation oncology medical physicists have developed professional guidelines for calculating staffing full-time equivalents (FTEs) related to linear accelerator hours per clinical day.
Methods: Queensland Public Health service managers were surveyed using a self-reported standardized data collection tool, requesting the FTE allied health staff provided for a number of services, including cancer care. Linear accelerator hours per clinical day were also collected. A linear regression model was employed to determine the relationship with the allied health workforce FTEs at linear accelerator sites.
Introduction Queensland Public Health cancer services have expanded in the past few years, with increasing numbers for chemotherapy chairs, treatment spaces, inpatient beds, and outreach services.1 With an expected increased demand in cancer care workforce requirements, resulting from increasing survival rates,2 the aging population, increasing levels of chronic disease, and community expectations,3 predicting future workforce needs is necessary. Current methods for predicting workforce models in cancer care for allied health professionals (AHPs) have been based on clinician knowledge, consensus, and historical staffing models.4,5 Radiation therapists and radiation oncology medical physicists have developed professional guidelines6-8 for calculating staffing full-time equivalents (FTEs) related to linear accelerator hours per clinical day. Identification of suitable denominators for workforce models must be easily accessible and comparable among services. The current treatment rate for radiotherapy for new patients with cancer is estimated to be 38.1%.8 Potentially, radiotherapy treatment rates provide an easily accessible indicator for new patients with cancer, rather than waiting for national data releases that may take years. Therefore, linear accelerator hours per clinical day may be a suitable denominator for the workforce. This study reviewed the workforce data for Queensland Public Health cancer care service AHPs correlated with linear accelerator hours per clinical day to determine whether a relationship existed. No quantitative data are available on the extent to which AHPs are engaged in cancer care in Australia.9 One in two 244
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Results: High correlations existed between linear accelerator hours per clinical day and radiation therapists (0.99), radiation oncology medical physicists (0.95), pharmacy services (pharmacists and assistants combined; 0.91), and rehabilitation allied health staff (⬎ 0.95). A linear regression model was employed to determine the allied health pharmacy service and rehabilitation workforce FTEs. Conclusion: In the four Queensland Public Health cancer care services with linear accelerators, radiation therapists, radiation oncology medical physicists, pharmacy services, and rehabilitation allied health staff, cancer care staff are highly correlated with linear accelerator hours per clinical day. The findings support identifying and establishing alternative denominators for allied health workforce requirements in cancer care beyond those of expert knowledge, opinion, and consensus.
Queenslanders will develop cancer in their lifetime (approximate lifetime risk to age 85 years),10 and with increasing survival rates,11 there are more people living with cancer, increasing the rehabilitation need. Rehabilitation is relevant at all stages of the care pathway, from diagnosis and treatment to survivorship, palliative care, and end-of-life care. The focus of the rehabilitation changes depending on a patient’s prognosis and ability. The term “rehabilitation AHP” has been adopted in the United Kingdom and includes, but is not exclusive to, dietitians, lymphedema practitioners, physiotherapists, occupational therapists, and speech and language therapists.12 Cancer rehabilitation workforce models have provided recommendations in rural cancer services4 and across the continuum of cancer care.5 A review of the methodology used to develop these workforce recommendations reveals reliance on expert knowledge, consensus, and opinion. Outcomes of these models demonstrate significant required increases above current service levels to meet recommendation guidelines. Workforce models that use objective denominators are required. We investigated the relationship between linear accelerator hours per clinical day and the allied health workforce to determine whether a relationship existed and, if so, its potential use in workforce modeling.
Methods Data Collection The four Queensland Public Health facilities that provide radiation services were asked to report on allied health FTEs for all
V O L . 10, I S S U E 4
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at UNIV OF PITTSBURGH, HSLS on March 8, 2015 from 132.174.255.116 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
By Juanine Passfield, M App Sci, Liam McQueen, and Julie Hulcombe
Inclusion Criteria Participants were AHPs employed by Queensland Health or Mater Health public services. Professions included were dietetics, occupational therapy, podiatry, pharmacy, psychology, physiotherapy, radiation oncology medical physics, radiation therapy (RT), radiography, speech pathology, and social work.
Exclusion Criteria Specialist statewide services were considered to disproportionately inflate single-site data and were therefore excluded (eg, gynecologic oncology unit at Royal Brisbane and Women’s Hospital, adolescent and young adult specialist projects). Also excluded were professionals working in support roles (eg, cancer care coordinators), where positions were not directly accountable for patient service provision.
Data Grouping Data grouping recognized that some AHP interventions diagnosed and treated cancer (ie, RT, radiation oncology medical physics, pharmacy), whereas others aimed to improve functional status by reducing impairment activity limitation and participation restriction, thereby enabling people to maximize their independence and quality of life through the cancer journey (ie, rehabilitation). The United Kingdom has adopted the term “cancer care rehabilitation AHP” to describe these professional groups. For the purposes of our study, this term included dietitians, occupational therapists, physiotherapists, podiatrists, psychologists, speech pathologists, and social workers. Staffing FTEs were separated for total cancer care workforce, RT, radiation oncology medical physics, pharmacy, lymphedema, and rehabilitation workforce. Linear accelerator hours per clinical day for September 2011 were requested from directors of RT. Correlations were determined between the service workforce data and linear accelerator hours per clinical day, with linear regression conducted where indicated.
Results There are four public linear accelerator services across Queensland: Cairns, Townsville, Royal Brisbane and Women’s HospiCopyright © 2014 by American Society of Clinical Oncology
J U L Y 2014
16 14 12 10 8 6 4 3 0
10
20
30
40
50
60
70
80
90
Linac Time (hours) Figure 1. Pharmacist and assistant combined staff full-time equivalents by linear accelerator (Linac) hours per clinical day. Blue diamonds represent Queensland Public Health facility.
tal, and Princess Alexandra Hospital/Mater Health; 171.25 linear accelerator hours per clinical day were reported during the data collection period for the four services.
Radiation Therapists and Radiation Oncology Medical Physicists A total of 239.2 radiation therapists work across the four Queensland Health radiation oncology services. A high correlation with the RT workforce (0.99) existed for linear accelerator hours per clinical day, demonstrating use of the established professional guidelines relating FTEs to linear accelerator hours. A total of 38 radiation oncology medical physicists work across three Queensland Health radiation oncology services; data from one site were unavailable. Analysis indicated a high correlation (0.95) for linear accelerator hours per clinical day, reflecting the adoption of established professional guidelines by Queensland Public Health services.
Pharmacists There were 19.7 pharmacists and 13 assistants located across the four sites. Correlations with linear accelerator hours per clinical day were as follows: pharmacists (0.78), assistants (0.90), and pharmacists and assistants combined (0.91). Because of the high correlations, linear regression was conducted for pharmacists and assistants combined. Linear regression revealed: staff FTE ⫽ 1.2339 ⫹ 0.1621 (linear accelerator hours per clinical day; 95% CI, ⫺0.061 to 0.386; P ⫽ .09; t ⫽ 3.12; Fig 1).
Rehabilitation Workforce Lymphedema workforce numbers were removed from analysis for the following reasons: services were provided by more than one profession; difficulty in attributing service provision to cancer-related diagnosis only; role of staff spanning the continuum of care, including survivorship and palliative care; and small workforce numbers (FTEs, 7.31). A total of 58 rehabilitation allied health staff were employed at the four services; no service reported specific podiatry staffing (Table 1; Appendix Fig A1, online only). •
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cancer-specific service provision to oncology inpatients and outpatients. The Allied Health Professions’ Office of Queensland requested that allied health managers coordinate, distribute, and collate their service data collection using a standardized data collection spreadsheet. Data were requested from each health facility between June and August 2011. Sites self-reported the number of actual FTEs provided to cancer care services. Reported FTE data included the variety of activities typically performed by the individual in a clinical role, as defined by the National Allied Health Casemix Committee.13 Activities included individual patient– and nonindividual patient–attributable activities, clinical services management, teaching and training, and research. Statewide cancer care workforce development officers from each region reviewed, adjusted, and validated the data in March and April 2012 for accuracy. Ethical approval was not sought for this study.
No. of Pharmacists and Pharmacy Assistants Combined
Allied Health Professional Workforce at Linear Accelerator Sites
Passfield, McQueen, and Hulcombe
Table 1. Rehabilitation Staffing at Linear Accelerator Services Listed by Profession Range
Total FTE
Dietetics
1.9-4
11.5
Occupational therapy
0.5-3.2
6.75
1.69
Physiotherapy
1.4-3.9
8.3
2.08
4.05
1.01
Psychology
0-2.05
Social work
3-5.5
Speech pathology
1.5-3
Average FTE 2.88
18.5
4.63
8.9
2.25
NOTE. Excludes lymphedema service provision. Abbreviation: FTE, full-time equivalent.
Because of the size and variability of individual profession data sets, data were combined to create a rehabilitation staffing group. The average number of rehabilitation AHP FTEs per linear accelerator hour per clinical day was 0.34. A high correlation existed for rehabilitation allied health and linear accelerator hours per clinical day (⬎ 0.95). Because of the high correlation, linear regression was conducted, which revealed: staff FTE ⫽ 8.783 ⫹ 0.134 (linear accelerator hours per clinical day; 95% CI, ⫺0.00647 to 0.27355; P ⫽ .055; t ⫽ 4.1; Fig 2).
Discussion
No. of Rehabilitation FTE Staff
For the four public health cancer care services with linear accelerators in Queensland, all allied health staffing seemed highly correlated (⬎ 0.90) with linear accelerator hours per clinical day. Linear regression conducted with this sample indicated a positive relationship; however, it cannot be concluded that a significant positive linear relationship exists between pharmacy staff or rehabilitation allied health staff and linear accelerator hours per clinical day, because both lower 95% CIs included zero. Visually good alignment with staffing and linear accelerator hours per clinical day was present. However, it is recognized that the limited sample size means discretion should be used in the interpretation of the statistical analysis performed. Further sampling of other services across Australia should be undertaken to increase the sample size and confidence in the data. 25 20 15 10 5
0
10
20
30
40
50
60
70
80
90
Linac Time (hours) Figure 2. Rehabilitation staff full-time equivalents (FTEs) by linear accelerator (Linac) hours per clinical day. Blue diamonds represent Queensland Public Health facility.
246
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Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at UNIV OF PITTSBURGH, HSLS on March 8, 2015 from 132.174.255.116 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Profession
Because public services were requested to provide inpatient and outpatient FTEs for cancer care, data were self-reported, representing a point in time (July to August 2011). It is noted that because cancer care occurs across a continuum, hospitalbased responses are likely to be focused on the diagnosis and planning, treatment, and post-treatment phases only. Data collection did not include service provision by community-based services, support groups, private practice, or other allied health cancer care services provided by nongovernment or other government agencies. It seems that the professional guidelines for staffing requirements for RT and radiation oncology medical physics are being used within Queensland Health. Adoption of guidelines is considered to improve workforce consistency and improve the ability to project future workforce requirements. Unlike other professions (eg, nursing, medicine), evidence for the use of staffing ratios for AHPs (eg, dietitians, occupational therapists, psychologists, physiotherapists, speech pathologists, and social workers) is scarce.14 Useful objective denominators are required to be identified and investigated. The ability to use linear accelerator hours per clinical day beyond the RT and radiation oncology medical physics workforce has potential benefits in workforce planning in the broader allied health cancer care workforce. Pharmacy services were correlated with linear accelerator hours per clinical day. Pharmacy services include both pharmacist and assistant and technician staff. The use of linear accelerator hours per clinical day may be an indicator of overall cancer activity, resulting in impacts on medication requirements for this population. The Society of Hospital Pharmacists of Australia recommends that pharmacist numbers be associated with the number of inpatient beds for oncology and hematology and number of day therapy beds or chairs.15 Models of care may also outsource reconstitution and production services, and the private workforce contribution may need to be considered. Further investigation is required to determine whether a model combining both linear accelerator hours per clinical day with bed and chair data may provide greater accuracy for calculating overall pharmacy service provision requirements. Data for rehabilitation staffing have been combined to increase sample size and account for variation in service delivery models. Services will vary in discipline mix because of the types of clients provided service, consideration of staffing skill mix and access to other services (eg, community based), services professional preference, and recognition of skill sharing and task delegation opportunities. Other factors that can influence workforce provision include the allocation of work, types of interventions offered, characteristics and management of available human resources, level of illness, and comorbidities.16 Further analysis is required to understand the profession-specific mix requirements for allied health rehabilitation cancer care services. In conclusion, in Queensland Public Health cancer care services with linear accelerators, RT, radiation oncology medical physics, pharmacy services, and rehabilitation allied health cancer care staff are highly correlated with linear accelerator hours
Allied Health Professional Workforce at Linear Accelerator Sites
per clinical day. Adoption of professional guidelines is apparent for radiation therapists and radiation oncology medical physicists at these services. The opportunity to use linear accelerator hours per clinical day for rehabilitation allied health and potentially pharmacy service staffing provision requires further investigation and consideration in workforce planning.
Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
Collection and assembly of data: Juanine Passfield Data analysis and interpretation: Liam McQueen Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Juanine Passfield, M App Sci, Level 1, 15 Butterworth St, Herston QLD 4006, PO Box 2368, Fortitude Valley, BC QLD 4006 Australia; e-mail: [email protected].
DOI: 10.1200/JOP.2013.001261; published online ahead of print at jop.ascopubs.org on May 20, 2014.
References 1. Queensland Government: State Budget 2010-11: Agency Budget Highlights—Queensland Health. http://www.health.qld.gov.au/publications/budget/ documents/10-11.pdf 2. Begg S, Vox T, Barker B, et al: The burden of disease and injury in Australia 2003. http://www.aihw.gov.au/publication-detail/?id⫽6442467990 3. Health Workforce Australia: The National Cancer Workforce Strategy (draft). Adelaide, South Australia, Australia, Health Workforce Australia, 2012 4. Western Australia Country Health Service: Delivering Quality Cancer Care in Rural Western Australia: Phase 1. Perth, Western Australia, Australia, Government of Western Australia, 2011 5. National Health Service: Cancer Rehabilitation Workforce Model Briefing Paper. Leeds, United Kingdom, National Health Service, 2011 6. Queensland Health: Health Service Planning Benchmarks: Recommendations For Linear Accelerator Services. Brisbane, Australia, State of Queensland, 2011 7. HealthConsult Pty Ltd: Radiation Oncology Workforce Planning, Final Report. Canberra, Australia, ACT, 2009 8. Radiation Oncology Reform Implementation Committee: Workforce reform framework. Canberra, Australia, Australian Department of Health, 2011
Copyright © 2014 by American Society of Clinical Oncology
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9. Cancer Australia, Cancer Council Australia: Review of National Cancer Control Activity in Australia. Canberra, Australia, Cancer Australia, 2010 10. Cancer Council Queensland, Queensland Health, Queensland Cancer Registry: Cancer in Queensland: Incidence, Mortality, Survival, Prevalence 19822008. Brisbane, Australia, Cancer Council Queensland, 2011 11. Australian Bureau of Statistics: Australian Social Trends: Life Expectancy Trends—Australia. www.abs.gov.au/socialtrends 12. National Health Service National Cancer Action Team: Cancer and Palliative Care Rehabilitation: A Review of the Evidence—Update. National Health Service, Leeds, United Kingdom, 2012 13. National Allied Health Casemix Committee: Health Activity Hierarchy Version 1.1. http://www.nahcc.org.au/pdfs/hah.pdf 14. Cartmill, L, Comans TA, Clark MJ, et al: Using staffing ratios for workforce planning: Evidence on nine allied health professions. http://www.humanresources-health.com/content/10/1/2 15. Society of Hospital Pharmacists of Australia: SHPA Standards of Practice for the Provision of Clinical Oncology Pharmacy Services. http://www.shpa.org.au/ lib/pdf/practice_standards/clinical_oncology_ro.pdf 16. Schoo AM, Boyce RA, Ridoutt L, et al: Workload capacity measures for estimating allied health staffing requirements. Aust Health Rev 32:548-558, 2008
•
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Acknowledgment We thank the Queensland Public Health allied health managers who cooperated to coordinate, distribute, and collate their service data submissions. This study was conducted by the Allied Health Professions’ Office of Queensland, Queensland Department of Health, Brisbane, Queensland, Australia. The Queensland Public Health allied health directors and the cancer care workforce provided the data.
Author Contributions Conception and design: Julie Hulcombe
Passfield, McQueen, and Hulcombe
Appendix
80
SP PT OT Diet Psych SW
60 40 20 0 1
2
3
4
Service Figure A1. Proportion of rehabilitation cancer care staff at linear accelerator services. Diet, dietitians; OT, occupational therapists; Psych, psychologists; PT, physiotherapists; SP, speech pathologists; SW, social workers.
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V O L . 10, I S S U E 4
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at UNIV OF PITTSBURGH, HSLS on March 8, 2015 from 132.174.255.116 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Discipline Staff (%)
100
Original Contribution
Workforce Profile for Allied Health Professions in Queensland Public Health Cancer Care Services With Linear Accelerators Department of Health, Queensland Government, Brisbane, Queensland, Australia
Abstract Purpose: This article profiles staffing levels for all allied health professionals in Queensland Public Health cancer care services to determine whether linear accelerator hours per clinical day are a potentially useful predictor of workforce requirements. Currently, radiation therapists and radiation oncology medical physicists have developed professional guidelines for calculating staffing full-time equivalents (FTEs) related to linear accelerator hours per clinical day.
Methods: Queensland Public Health service managers were surveyed using a self-reported standardized data collection tool, requesting the FTE allied health staff provided for a number of services, including cancer care. Linear accelerator hours per clinical day were also collected. A linear regression model was employed to determine the relationship with the allied health workforce FTEs at linear accelerator sites.
Introduction Queensland Public Health cancer services have expanded in the past few years, with increasing numbers for chemotherapy chairs, treatment spaces, inpatient beds, and outreach services.1 With an expected increased demand in cancer care workforce requirements, resulting from increasing survival rates,2 the aging population, increasing levels of chronic disease, and community expectations,3 predicting future workforce needs is necessary. Current methods for predicting workforce models in cancer care for allied health professionals (AHPs) have been based on clinician knowledge, consensus, and historical staffing models.4,5 Radiation therapists and radiation oncology medical physicists have developed professional guidelines6-8 for calculating staffing full-time equivalents (FTEs) related to linear accelerator hours per clinical day. Identification of suitable denominators for workforce models must be easily accessible and comparable among services. The current treatment rate for radiotherapy for new patients with cancer is estimated to be 38.1%.8 Potentially, radiotherapy treatment rates provide an easily accessible indicator for new patients with cancer, rather than waiting for national data releases that may take years. Therefore, linear accelerator hours per clinical day may be a suitable denominator for the workforce. This study reviewed the workforce data for Queensland Public Health cancer care service AHPs correlated with linear accelerator hours per clinical day to determine whether a relationship existed. No quantitative data are available on the extent to which AHPs are engaged in cancer care in Australia.9 One in two 244
JOURNAL
OF
ONCOLOGY PRACTICE
•
Results: High correlations existed between linear accelerator hours per clinical day and radiation therapists (0.99), radiation oncology medical physicists (0.95), pharmacy services (pharmacists and assistants combined; 0.91), and rehabilitation allied health staff (⬎ 0.95). A linear regression model was employed to determine the allied health pharmacy service and rehabilitation workforce FTEs. Conclusion: In the four Queensland Public Health cancer care services with linear accelerators, radiation therapists, radiation oncology medical physicists, pharmacy services, and rehabilitation allied health staff, cancer care staff are highly correlated with linear accelerator hours per clinical day. The findings support identifying and establishing alternative denominators for allied health workforce requirements in cancer care beyond those of expert knowledge, opinion, and consensus.
Queenslanders will develop cancer in their lifetime (approximate lifetime risk to age 85 years),10 and with increasing survival rates,11 there are more people living with cancer, increasing the rehabilitation need. Rehabilitation is relevant at all stages of the care pathway, from diagnosis and treatment to survivorship, palliative care, and end-of-life care. The focus of the rehabilitation changes depending on a patient’s prognosis and ability. The term “rehabilitation AHP” has been adopted in the United Kingdom and includes, but is not exclusive to, dietitians, lymphedema practitioners, physiotherapists, occupational therapists, and speech and language therapists.12 Cancer rehabilitation workforce models have provided recommendations in rural cancer services4 and across the continuum of cancer care.5 A review of the methodology used to develop these workforce recommendations reveals reliance on expert knowledge, consensus, and opinion. Outcomes of these models demonstrate significant required increases above current service levels to meet recommendation guidelines. Workforce models that use objective denominators are required. We investigated the relationship between linear accelerator hours per clinical day and the allied health workforce to determine whether a relationship existed and, if so, its potential use in workforce modeling.
Methods Data Collection The four Queensland Public Health facilities that provide radiation services were asked to report on allied health FTEs for all
V O L . 10, I S S U E 4
Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at UNIV OF PITTSBURGH, HSLS on March 8, 2015 from 132.174.255.116 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
By Juanine Passfield, M App Sci, Liam McQueen, and Julie Hulcombe
Inclusion Criteria Participants were AHPs employed by Queensland Health or Mater Health public services. Professions included were dietetics, occupational therapy, podiatry, pharmacy, psychology, physiotherapy, radiation oncology medical physics, radiation therapy (RT), radiography, speech pathology, and social work.
Exclusion Criteria Specialist statewide services were considered to disproportionately inflate single-site data and were therefore excluded (eg, gynecologic oncology unit at Royal Brisbane and Women’s Hospital, adolescent and young adult specialist projects). Also excluded were professionals working in support roles (eg, cancer care coordinators), where positions were not directly accountable for patient service provision.
Data Grouping Data grouping recognized that some AHP interventions diagnosed and treated cancer (ie, RT, radiation oncology medical physics, pharmacy), whereas others aimed to improve functional status by reducing impairment activity limitation and participation restriction, thereby enabling people to maximize their independence and quality of life through the cancer journey (ie, rehabilitation). The United Kingdom has adopted the term “cancer care rehabilitation AHP” to describe these professional groups. For the purposes of our study, this term included dietitians, occupational therapists, physiotherapists, podiatrists, psychologists, speech pathologists, and social workers. Staffing FTEs were separated for total cancer care workforce, RT, radiation oncology medical physics, pharmacy, lymphedema, and rehabilitation workforce. Linear accelerator hours per clinical day for September 2011 were requested from directors of RT. Correlations were determined between the service workforce data and linear accelerator hours per clinical day, with linear regression conducted where indicated.
Results There are four public linear accelerator services across Queensland: Cairns, Townsville, Royal Brisbane and Women’s HospiCopyright © 2014 by American Society of Clinical Oncology
J U L Y 2014
16 14 12 10 8 6 4 3 0
10
20
30
40
50
60
70
80
90
Linac Time (hours) Figure 1. Pharmacist and assistant combined staff full-time equivalents by linear accelerator (Linac) hours per clinical day. Blue diamonds represent Queensland Public Health facility.
tal, and Princess Alexandra Hospital/Mater Health; 171.25 linear accelerator hours per clinical day were reported during the data collection period for the four services.
Radiation Therapists and Radiation Oncology Medical Physicists A total of 239.2 radiation therapists work across the four Queensland Health radiation oncology services. A high correlation with the RT workforce (0.99) existed for linear accelerator hours per clinical day, demonstrating use of the established professional guidelines relating FTEs to linear accelerator hours. A total of 38 radiation oncology medical physicists work across three Queensland Health radiation oncology services; data from one site were unavailable. Analysis indicated a high correlation (0.95) for linear accelerator hours per clinical day, reflecting the adoption of established professional guidelines by Queensland Public Health services.
Pharmacists There were 19.7 pharmacists and 13 assistants located across the four sites. Correlations with linear accelerator hours per clinical day were as follows: pharmacists (0.78), assistants (0.90), and pharmacists and assistants combined (0.91). Because of the high correlations, linear regression was conducted for pharmacists and assistants combined. Linear regression revealed: staff FTE ⫽ 1.2339 ⫹ 0.1621 (linear accelerator hours per clinical day; 95% CI, ⫺0.061 to 0.386; P ⫽ .09; t ⫽ 3.12; Fig 1).
Rehabilitation Workforce Lymphedema workforce numbers were removed from analysis for the following reasons: services were provided by more than one profession; difficulty in attributing service provision to cancer-related diagnosis only; role of staff spanning the continuum of care, including survivorship and palliative care; and small workforce numbers (FTEs, 7.31). A total of 58 rehabilitation allied health staff were employed at the four services; no service reported specific podiatry staffing (Table 1; Appendix Fig A1, online only). •
jop.ascopubs.org
245
Information downloaded from jop.ascopubs.org and provided by at UNIV OF PITTSBURGH, HSLS on March 8, 2015 from 132.174.255.116 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
cancer-specific service provision to oncology inpatients and outpatients. The Allied Health Professions’ Office of Queensland requested that allied health managers coordinate, distribute, and collate their service data collection using a standardized data collection spreadsheet. Data were requested from each health facility between June and August 2011. Sites self-reported the number of actual FTEs provided to cancer care services. Reported FTE data included the variety of activities typically performed by the individual in a clinical role, as defined by the National Allied Health Casemix Committee.13 Activities included individual patient– and nonindividual patient–attributable activities, clinical services management, teaching and training, and research. Statewide cancer care workforce development officers from each region reviewed, adjusted, and validated the data in March and April 2012 for accuracy. Ethical approval was not sought for this study.
No. of Pharmacists and Pharmacy Assistants Combined
Allied Health Professional Workforce at Linear Accelerator Sites
Passfield, McQueen, and Hulcombe
Table 1. Rehabilitation Staffing at Linear Accelerator Services Listed by Profession Range
Total FTE
Dietetics
1.9-4
11.5
Occupational therapy
0.5-3.2
6.75
1.69
Physiotherapy
1.4-3.9
8.3
2.08
4.05
1.01
Psychology
0-2.05
Social work
3-5.5
Speech pathology
1.5-3
Average FTE 2.88
18.5
4.63
8.9
2.25
NOTE. Excludes lymphedema service provision. Abbreviation: FTE, full-time equivalent.
Because of the size and variability of individual profession data sets, data were combined to create a rehabilitation staffing group. The average number of rehabilitation AHP FTEs per linear accelerator hour per clinical day was 0.34. A high correlation existed for rehabilitation allied health and linear accelerator hours per clinical day (⬎ 0.95). Because of the high correlation, linear regression was conducted, which revealed: staff FTE ⫽ 8.783 ⫹ 0.134 (linear accelerator hours per clinical day; 95% CI, ⫺0.00647 to 0.27355; P ⫽ .055; t ⫽ 4.1; Fig 2).
Discussion
No. of Rehabilitation FTE Staff
For the four public health cancer care services with linear accelerators in Queensland, all allied health staffing seemed highly correlated (⬎ 0.90) with linear accelerator hours per clinical day. Linear regression conducted with this sample indicated a positive relationship; however, it cannot be concluded that a significant positive linear relationship exists between pharmacy staff or rehabilitation allied health staff and linear accelerator hours per clinical day, because both lower 95% CIs included zero. Visually good alignment with staffing and linear accelerator hours per clinical day was present. However, it is recognized that the limited sample size means discretion should be used in the interpretation of the statistical analysis performed. Further sampling of other services across Australia should be undertaken to increase the sample size and confidence in the data. 25 20 15 10 5
0
10
20
30
40
50
60
70
80
90
Linac Time (hours) Figure 2. Rehabilitation staff full-time equivalents (FTEs) by linear accelerator (Linac) hours per clinical day. Blue diamonds represent Queensland Public Health facility.
246
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Copyright © 2014 by American Society of Clinical Oncology
Information downloaded from jop.ascopubs.org and provided by at UNIV OF PITTSBURGH, HSLS on March 8, 2015 from 132.174.255.116 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Profession
Because public services were requested to provide inpatient and outpatient FTEs for cancer care, data were self-reported, representing a point in time (July to August 2011). It is noted that because cancer care occurs across a continuum, hospitalbased responses are likely to be focused on the diagnosis and planning, treatment, and post-treatment phases only. Data collection did not include service provision by community-based services, support groups, private practice, or other allied health cancer care services provided by nongovernment or other government agencies. It seems that the professional guidelines for staffing requirements for RT and radiation oncology medical physics are being used within Queensland Health. Adoption of guidelines is considered to improve workforce consistency and improve the ability to project future workforce requirements. Unlike other professions (eg, nursing, medicine), evidence for the use of staffing ratios for AHPs (eg, dietitians, occupational therapists, psychologists, physiotherapists, speech pathologists, and social workers) is scarce.14 Useful objective denominators are required to be identified and investigated. The ability to use linear accelerator hours per clinical day beyond the RT and radiation oncology medical physics workforce has potential benefits in workforce planning in the broader allied health cancer care workforce. Pharmacy services were correlated with linear accelerator hours per clinical day. Pharmacy services include both pharmacist and assistant and technician staff. The use of linear accelerator hours per clinical day may be an indicator of overall cancer activity, resulting in impacts on medication requirements for this population. The Society of Hospital Pharmacists of Australia recommends that pharmacist numbers be associated with the number of inpatient beds for oncology and hematology and number of day therapy beds or chairs.15 Models of care may also outsource reconstitution and production services, and the private workforce contribution may need to be considered. Further investigation is required to determine whether a model combining both linear accelerator hours per clinical day with bed and chair data may provide greater accuracy for calculating overall pharmacy service provision requirements. Data for rehabilitation staffing have been combined to increase sample size and account for variation in service delivery models. Services will vary in discipline mix because of the types of clients provided service, consideration of staffing skill mix and access to other services (eg, community based), services professional preference, and recognition of skill sharing and task delegation opportunities. Other factors that can influence workforce provision include the allocation of work, types of interventions offered, characteristics and management of available human resources, level of illness, and comorbidities.16 Further analysis is required to understand the profession-specific mix requirements for allied health rehabilitation cancer care services. In conclusion, in Queensland Public Health cancer care services with linear accelerators, RT, radiation oncology medical physics, pharmacy services, and rehabilitation allied health cancer care staff are highly correlated with linear accelerator hours
Allied Health Professional Workforce at Linear Accelerator Sites
per clinical day. Adoption of professional guidelines is apparent for radiation therapists and radiation oncology medical physicists at these services. The opportunity to use linear accelerator hours per clinical day for rehabilitation allied health and potentially pharmacy service staffing provision requires further investigation and consideration in workforce planning.
Authors’ Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
Collection and assembly of data: Juanine Passfield Data analysis and interpretation: Liam McQueen Manuscript writing: All authors Final approval of manuscript: All authors Corresponding author: Juanine Passfield, M App Sci, Level 1, 15 Butterworth St, Herston QLD 4006, PO Box 2368, Fortitude Valley, BC QLD 4006 Australia; e-mail: [email protected].
DOI: 10.1200/JOP.2013.001261; published online ahead of print at jop.ascopubs.org on May 20, 2014.
References 1. Queensland Government: State Budget 2010-11: Agency Budget Highlights—Queensland Health. http://www.health.qld.gov.au/publications/budget/ documents/10-11.pdf 2. Begg S, Vox T, Barker B, et al: The burden of disease and injury in Australia 2003. http://www.aihw.gov.au/publication-detail/?id⫽6442467990 3. Health Workforce Australia: The National Cancer Workforce Strategy (draft). Adelaide, South Australia, Australia, Health Workforce Australia, 2012 4. Western Australia Country Health Service: Delivering Quality Cancer Care in Rural Western Australia: Phase 1. Perth, Western Australia, Australia, Government of Western Australia, 2011 5. National Health Service: Cancer Rehabilitation Workforce Model Briefing Paper. Leeds, United Kingdom, National Health Service, 2011 6. Queensland Health: Health Service Planning Benchmarks: Recommendations For Linear Accelerator Services. Brisbane, Australia, State of Queensland, 2011 7. HealthConsult Pty Ltd: Radiation Oncology Workforce Planning, Final Report. Canberra, Australia, ACT, 2009 8. Radiation Oncology Reform Implementation Committee: Workforce reform framework. Canberra, Australia, Australian Department of Health, 2011
Copyright © 2014 by American Society of Clinical Oncology
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9. Cancer Australia, Cancer Council Australia: Review of National Cancer Control Activity in Australia. Canberra, Australia, Cancer Australia, 2010 10. Cancer Council Queensland, Queensland Health, Queensland Cancer Registry: Cancer in Queensland: Incidence, Mortality, Survival, Prevalence 19822008. Brisbane, Australia, Cancer Council Queensland, 2011 11. Australian Bureau of Statistics: Australian Social Trends: Life Expectancy Trends—Australia. www.abs.gov.au/socialtrends 12. National Health Service National Cancer Action Team: Cancer and Palliative Care Rehabilitation: A Review of the Evidence—Update. National Health Service, Leeds, United Kingdom, 2012 13. National Allied Health Casemix Committee: Health Activity Hierarchy Version 1.1. http://www.nahcc.org.au/pdfs/hah.pdf 14. Cartmill, L, Comans TA, Clark MJ, et al: Using staffing ratios for workforce planning: Evidence on nine allied health professions. http://www.humanresources-health.com/content/10/1/2 15. Society of Hospital Pharmacists of Australia: SHPA Standards of Practice for the Provision of Clinical Oncology Pharmacy Services. http://www.shpa.org.au/ lib/pdf/practice_standards/clinical_oncology_ro.pdf 16. Schoo AM, Boyce RA, Ridoutt L, et al: Workload capacity measures for estimating allied health staffing requirements. Aust Health Rev 32:548-558, 2008
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Acknowledgment We thank the Queensland Public Health allied health managers who cooperated to coordinate, distribute, and collate their service data submissions. This study was conducted by the Allied Health Professions’ Office of Queensland, Queensland Department of Health, Brisbane, Queensland, Australia. The Queensland Public Health allied health directors and the cancer care workforce provided the data.
Author Contributions Conception and design: Julie Hulcombe
Passfield, McQueen, and Hulcombe
Appendix
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SP PT OT Diet Psych SW
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Service Figure A1. Proportion of rehabilitation cancer care staff at linear accelerator services. Diet, dietitians; OT, occupational therapists; Psych, psychologists; PT, physiotherapists; SP, speech pathologists; SW, social workers.
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Information downloaded from jop.ascopubs.org and provided by at UNIV OF PITTSBURGH, HSLS on March 8, 2015 from 132.174.255.116 Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Discipline Staff (%)
100
