Patterns of change in evidence-based practice competence following a team-based learning intervention: a quasi-experimental study.

Geographical inequities in social determinants of health, healthcare access, the cost of services, and health outcomes are widespread across many regions globally [–]. These inequities include differential direct and indirect out-of-pocket costs for accessing healthcare among people who reside in rural, regional, or remote areas []. This issue is particularly salient in jurisdictions where large distances between residential locations and specialised healthcare services create barriers to timely access. Out-of-pocket cost inequity can be exacerbated when specialised services are concentrated in major metropolitan centres, requiring families to travel long distances for care. This is particularly relevant for children with congenital heart disease who are at elevated risk of neurodevelopmental delays and may require ongoing neurodevelopmental screening, assessment, referral and intervention in early childhood []. Despite advances in virtual care, face-to-face consultations remain necessary for neurodevelopmental assessment and support for many children with congenital heart disease, particularly infants and toddlers []. In some regions, including Australia [], Canada [], and France [], efforts have been made to support decentralised models of neurodevelopmental follow-up when care does not need to be solely delivered at metropolitan paediatric cardiac centres []. The Congenital Heart Disease Long-term Improvement in Functional hEalth (CHD LIFE) program in Queensland, Australia, is an established example of these efforts that has been previously described and is relevant to the present study []. Among Australian states, which each have their own unique geographies and health service profiles, Queensland was selected for this study as an informative use case to examine how alternative policy settings may influence family out-of-pocket costs, specifically in relation to the geographical location of neurodevelopment-related service provision. The state spans sparsely populated rural and remote areas, regional centres, and major metropolitan areas, and has healthcare infrastructure with potential to support service delivery in differing locations. In a recent study, we quantified geographical inequity in access to tertiary-hospital-based specialised services for families in rural, regional, and remote areas across Queensland []. Mapping of patient residences and service locations demonstrated that a substantial proportion of high-risk patients live large distances from tertiary-level care []. However, that work did not quantify the likely magnitude of out-of-pocket cost differences for families under alternative service location scenarios for face-to-face neurodevelopment care. While there are many factors that must be considered when evaluating policy response options, including clinical effectiveness, safety, workforce capacity, consumer preferences, and implementation feasibility, the potential impact on family out-of-pocket costs is an important consideration for informing equitable service design. Policy responses that support decentralisation of services, where possible and clinically appropriate, to enable neurodevelopment-related care to be delivered closer to home, are a plausible strategy to reduce geographical inequity [, , , , ]. In the context of highly developed healthcare systems with overlapping state and federal initiatives intended to reduce geographic inequities, it is important to anticipate potential consequences for patients and families to avoid negative unintended effects. However, nuanced, policy-relevant economic modelling to estimate the potential financial impacts on patients and families has typically not been present in prior research in the field [].