Dr Gabby Diplock
GP Registrar, Alice Springs & Tennant Creek

Dr Gabrielle Diplock is a GP registrar currently working in Alice Springs and Tennant Creek. She has lived and worked in the NT for more than 10 years. Gabrielle has an interest in indigenous health and chronic disease management. She is currently completing her PhD at Baker IDI Central Australia. Her project, The Alice Springs Hospital Readmission Prevention Project is an NHMRC funded randomised control trial investigating whether a tailored transitional care approach is effective in reducing readmission rates for patients at risk of recurrent readmission when compared to usual care.  


Title: The Alice Springs Hospital Readmission Prevention Project (ASHRAPP):  A Randomised Control Trial
Authors/Affiliations: Gabrielle Diplock1, James Ward2, Simon Stewart3, Paul Schuffham4 Carole Reeve5, Penny Stewart5, Lea Davidson5, Mick Arundell5, Graeme Maguire1
1 Baker IDI Heart & Diabetes Institute, Alice Springs, Australia
2 South Australian Health & Medical Research Institute, Adelaide, Australia
3 Mary MacKillop Institute for Health Research, Melbourne, Australia
4 Griffith University, Brisbane, Australia
5 Alice Springs Hospital, Alice Springs, Australia

Aims: Transitional care involves a broad range of services designed to facilitate safe and timely passage of patients across healthcare settings. High quality transitional care is especially important for adults with complex chronic disease. Our aim is to evaluate the efficacy of a transitional care package for patients at risk of recurrent readmission with the aim of reducing readmission rates and improving transition to primary care.

Methods: The project is a randomised control trial comparing a tailored, multidimensional transitional care package to usual care at Alice Springs Hospital. Patients will be recruited from medical and general surgical admissions and will be followed for 12 months. The primary outcome measure will be number of admissions to hospital with secondary outcomes including time to primary care review post discharge, number of ED presentations, Length of admissions, number of ICU admissions and days alive and out of hospital. An economic analysis of the cost of recurrent readmissions and the intervention will be conducted after completion of the project.

Results: The project will be 14 months into the 24 month recruitment phase by September. Approximately 80% of patients are Indigenous people from both Alice Springs and remote communities. Patients have multiple co-morbidities including bronchiectasis, heart failure, diabetes and chronic kidney disease. Drivers for readmission include acute deterioration of chronic conditions, missed medications, lack of social supports and issues relating to homelessness and alcohol. An interim analysis of the data will be available at time of presentation.

Conclusions: Successful transition from hospital to primary care is important for patients with complex chronic disease. Whilst there is a developing evidence base to inform transitional care programs in urban, non-Indigenous settings, there is a paucity of evidence to direct such initiatives for Aboriginal Australians particularly in remote Australia. This project will contribute to this evidence base.