Strengthening Care for Children Using a Virtual Integrated General Practitioner-Pediatrician Model of Primary Care (SUSTAIN): Protocol for a Stepped Wedge Cluster Randomized Controlled Trial.

Background: Australia's health care system is under pressure. Pediatric referrals to public hospital emergency and outpatient departments have increased recently, overburdening emergency services and resulting in extended waiting times for nonurgent pediatric care. Children living outside metropolitan areas are disproportionately affected. Integrated models of care with pediatricians collaborating with general practitioners (GPs) in their practices have been evaluated in the United Kingdom and Australia. Results are promising for quality of care improvement and reducing referrals to hospitals. GPs and pediatricians found the model feasible, knowledge- and confidence-boosting. In-person pediatric-GP support is resource-intensive, limiting scalability and sustainability. Objective: The SUSTAIN trial is designed to evaluate a digitally delivered, integrated GP-pediatrician model of care. The primary objective is to determine whether the SUSTAIN model reduces GP referrals to hospital emergency departments for children <18 years. Secondary objectives include whether the model improves the delivery of guideline-concordant pediatric care by GPs, enhances GP confidence, and strengthens family trust in primary care. The trial also examines barriers and enablers to the implementation and includes a health economic evaluation comparing intervention costs with standard GP care. Methods: SUSTAIN uses a stepped wedge cluster randomized controlled trial design to implement a GP-pediatrician integrated model of care delivered digitally. Participating GP practices across metropolitan and nonmetropolitan New South Wales are included and randomly assigned a start time. The intervention consists of 12 months' access to the shared GP-pediatrician consulting sessions with patients younger than 18 years conducted by telehealth, virtual pediatrician-led case discussions, phone/email pediatrician support, and complimentary access to the internationally renowned Sydney Child Health Program learning platform. GP and family surveys are collected at baseline and in the final month of intervention. An implementation evaluation using focus group discussions is conducted with each practice during the intervention and optional GP and family interviews at the end of the intervention. A health economic evaluation will explore the cost-effectiveness of this model of care. Results: The trial is supported through a 2.5-year New South Wales Ministry of Health Translational Research Grants Scheme. Human Research Ethics Committee approval was obtained in November 2022, and practice recruitment began in March 2023. Data collection commenced for all participating practices from September 1, 2023, with anticipated completion on February 28, 2025. Data analysis will commence from March 2025, with results expected in the first quarter of 2026. Conclusions: Positive outcomes for the SUSTAIN trial, demonstrating that virtual pediatric support for GPs in both metropolitan and nonmetropolitan areas can strengthen pediatric primary care provision, have the potential to influence future health policy. This innovative approach to integrated care could be rolled out across Australia and other countries with primary care-led health care systems facing similar challenges.