Diagnostic Delay and Disease Burden in Primary Aldosteronism: An International Patient Survey

BACKGROUND

Primary aldosteronism (PA) is a common but underdiagnosed cause of hypertension. Many patients experience preventable end-organ injury due to delayed or missed diagnosis but data on the experience of patients are limited.

METHODS

We evaluated the lived experience of PA and determines factors associated with diagnostic delay through an international anonymous online cross-sectional survey, codesigned by researchers and PA consumers. We distributed the survey through academic medical centers, Amazon Mechanical Turk, Twitter, PA patient advocacy groups, and hypertension support groups on Facebook between March 21 and June 5, 2022.

RESULTS

Of 684 eligible respondents, 66.5% were women. Diagnostic delay (defined as ≥5 years between the diagnosis of hypertension and PA) was reported in 35.6%. Delay was more likely in women than in men (odds ratio, 1.55 [95% CI, 1.10-2.20]) and respondents with ≥3 comorbidities versus none (odds ratio, 1.77 [95% CI, 1.05-3.02]), ≥10 symptoms versus none (odds ratio, 2.73 [95% CI, 1.74-4.44]), and on ≥4 antihypertensive medications versus none (odds ratio, 18.23 [95% CI, 6.24-77.72]). Three-quarters of patients (74.4%) experienced reduced symptom burden following targeted PA treatment. Quality of life improved in 62.3% of patients, and greater improvement was associated with being a woman (odds ratio, 1.42, [95% CI, 1.02-1.97]), receiving adrenalectomy (odds ratio, 2.36 [95% CI, 1.67-3.35]), and taking fewer antihypertensive medications following diagnosis (odds ratio, 5.28 [95% CI, 3.55-7.90]).

CONCLUSIONS

One-third of patients with PA experienced prolonged diagnostic delays. Targeted treatment led to reduced symptom burden and improved quality of life. Gender differences in diagnostic delay and symptom burden are prominent. These findings suggest that routine screening for PA at the onset of hypertension may reduce diagnostic delay and facilitate timely diagnosis.

Mental health systems modelling for evidence-informed service reform in Australia

Australia's Fifth National Mental Health Plan required governments to report, not only on the progress of changes to mental health service delivery, but to also plan for services that should be provided. Future population demand for treatment and care is challenging to predict and one solution involves modelling the uncertain demands on the system. Modelling can help decision-makers understand likely future changes in mental health service demand and more intelligently choose appropriate responses. It can also support greater scrutiny, accountability and transparency of these processes. Australia has an emerging national capacity for systems modelling in mental health which can enhance the next phase of mental health reform. This paper introduces concepts useful for understanding mental health modelling and identifies where modelling approaches can support health service planners to make evidence-informed decisions regarding planning and investment for the Australian population.

Willingness to be tested for a secondary cause of hypertension: a survey of the Australian general community

BACKGROUND

Primary aldosteronism (PA) represents the most common and potentially curable cause of secondary hypertension. However, PA is not commonly screened for, and up to 34% of patients who screen positive do not complete the full diagnostic process. This suggests that the diagnostic process may pose a barrier to patients and may contribute to the under-diagnosis of PA.

AIMS

To evaluate the willingness of the Australian general public to undergo testing for secondary causes of hypertension and identify enablers or barriers to testing from the patients' perspective.

METHODS

An online survey containing questions on knowledge and attitudes towards hypertension, willingness to be tested and enablers/barriers towards testing was distributed to the Australian community.

RESULTS

Of 520 adult respondents (mean age 50.4 years, SD 27.3 years; 28.8% hypertensive; 56.0% female), the majority of non-hypertensive and hypertensive respondents (82.7% vs 70.0%; P = 0.03) were willing to undergo testing for a secondary cause of hypertension that involved blood and urine tests. Greater knowledge of hypertensive risk modification strategies and complications was predictive of willingness to be tested, whereas age, sex, education level, geographic location, socio-economic status and cardiovascular comorbidities were not. The top three barriers to testing included fear of a serious underlying condition, lack of belief in further testing and increased stress associated with further testing.

CONCLUSION

A high proportion of patients are willing to engage in testing for a secondary cause of hypertension. Education about the risks associated with hypertension and the testing process may overcome several barriers to testing.

English language proficiency and hospital admissions via the emergency department by aged care residents in Australia: A mixed-methods investigation

Residents of Residential Age Care Facilities (RACFs) have particularly high rates of Emergency Department (ED) visits, with up to 55% being potentially avoidable (e.g. not resulting in a hospital admission). This is concerning as ED visits by RACF residents are associated with negative outcomes including longer hospital stays, iatrogenic illness, complications and mortality. Limited English proficiency (LEP) has significant negative impacts on the healthcare quality and outcomes for older people but has not been studied as a factor in ED visits from RACFs. This study aimed to examine if RACF residents with LEP have a lower rate of hospital admission via the ED compared to non-LEP controls and identify any associated factors. We hypothesised that LEP-related communication difficulties would reduce the ability to manage minor health issues in the RACF, leading to a lower proportion of LEP ED transfers being admitted. We used a parallel mixed-methods design, comprising a quantitative matched cohort study of ED visit data from two Local Hospital Networks (LHNs) in South-East Melbourne, Australia and secondary thematic analysis of 25 interviews with LEP residents, family carers and staff from two RACFs in the same region. We found no differences in the proportion of hospital ED transfers that led to admission (LHN1, 87.1% LEP, 85.6% non-LEP controls, p = 0.57; LHN2, 76.0% LEP, 76.9% non-LEP controls, p = 0.41) and no direct qualitative evidence suggesting that resident LEP affected decisions to transfer residents to ED, despite communication difficulties being reported during the transfer process. These results may be due to the high level of family carer involvement in residents' care identified in the qualitative study. However, additional research using different measures of LEP is recommended to further explore a broader range of cultural and linguistic factors in both rates of ED presentations and the decision-making processes underpinning resident transfers to ED.

Australian public health COVID-19 messaging is missing its mark in some vulnerable communities and people who reject COVID-19 safety advice

Background

There are groups in our community who may be more vulnerable to contracting, transmitting, or experiencing negative health impacts of COVID-19 than the general community. They may also have greater difficulty accessing, accepting, and acting upon COVID-19 public health information. Our aim was to understand if vulnerable communities and those who express "COVID-risk" behavioural intentions seek and respond differently to COVID-19 public health information.

Methods

This observational, cross-sectional study recruited adults aged over 18 years from the Australian general community and six community groups (people with disabilities and their caregivers, Aboriginal and Torres Strait Islanders, aged care workers, street-based sex workers, refugees and asylum seekers, and the deaf and hard of hearing). We investigated attitudes and beliefs about COVID-19 public health messages. We identified factors associated with the respondent's perception of the ease of finding information and understanding it, and its relevance to them. We also examined latent classes that were developed based on attitudes to public health measures and vulnerable group categories, along with demographic variables.

Results

We received 1444 responses (n = 1121 general community; n ≥50 for each vulnerable group). The vulnerable groups examined found COVID-19 public health messages as easy, if not easier, to find and understand than the general community. Four latent classes were identified: COVID-safe mask wearers (10% of sample), COVID-safe test takers (56%), COVID-risk isolators (19%) and COVID-risk visitors (15%). The COVID-risk classes (34% of sample) were less likely to consider COVID-19 information easy to find, understandable, and relevant.

Conclusions

Additional public health messaging strategies may be needed for targeting people with "COVID-risk" beliefs and attitudes who appear across the community (general and vulnerable groups) rather than just targeting specific cultural or other groupings that we think may be vulnerable. COVID-risk classes identified through this study were not defined by demographic characteristics or cultural groupings, but were spread across vulnerable communities and the general community. Different approaches for tailoring and delivery of specific public health information for these groups are needed.

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial

BACKGROUND

Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services.

METHODS AND FINDINGS

This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control β 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control β 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker β -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control β 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control β -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker β -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control β 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control β -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker β -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination.

CONCLUSIONS

Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Response to language barriers with patients from refugee background in general practice in Australia: findings from the OPTIMISE study

Background

Language is a barrier to many patients from refugee backgrounds accessing and receiving quality primary health care. This paper examines the way general practices address these barriers and how this changed following a practice facilitation intervention.

Methods

The OPTIMISE study was a stepped wedge cluster randomised trial set within 31 general practices in three urban regions in Australia with high refugee settlement. It involved a practice facilitation intervention addressing interpreter engagement as one of four core intervention areas. This paper analysed quantitative and qualitative data from the practices and 55 general practitioners from these, collected at baseline and after 6 months during which only those assigned to the early group received the intervention.

Results

Many practices (71 %) had at least one GP who spoke a language spoken by recent humanitarian entrants. At baseline, 48 % of practices reported using the government funded Translating and Interpreting Service (TIS). The role of reception staff in assessing and recording the language and interpreter needs of patients was well defined. However, they lacked effective systems to share the information with clinicians. After the intervention, the number of practices using the TIS increased. However, family members and friends continued to be used to interpret with GPs reporting patients preferred this approach. The extra time required to arrange and use interpreting services remained a major barrier.

Conclusions

In this study a whole of practice facilitation intervention resulted in improvements in procedures for and engagement of interpreters. However, there were barriers such as the extra time required, and family members continued to be used. Based on these findings, further effort is needed to reduce the administrative burden and GP’s opportunity cost needed to engage interpreters, to provide training for all staff on when and how to work with interpreters and discuss and respond to patient concerns about interpreting services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06884-5.

Improving access to refugee-focused health services for people from refugee-like backgrounds in south-eastern Melbourne through the education sector

People from refugee-like backgrounds living in Australia face substantial health challenges that benefit from access to health and social services. Many people from refugee-like backgrounds have frequent contact with education sector staff, who have the potential to act as conduits to health and social services. The aim of this project was to improve access to refugee-focused health services for people from refugee-like backgrounds in south-eastern Melbourne by codesigning and delivering a 1-day education forum to education sector staff. Evaluation of the forum used mixed-methods analysis of data from pre-post and follow-up surveys (n =11; administered before, immediately after and 1 month after the forum respectively), post-forum interviews (n =4) and one school's referral records. The forum improved attendees' refugee-focused health service referral knowledge, confidence and behaviour. This was supported by the qualitative findings of high staff motivation, high forum satisfaction and evidence of outcome sustainability. Education staff are an important complement to an integrated model of health care for recently resettled people from refugee-like backgrounds. These results show that a straightforward local intervention can improve the ability of education staff to act as conduits to health services, increasing access to health services for people from refugee-like backgrounds.

Engaging Healthcare Staff and Stakeholders in Healthcare Simulation Modeling to Better Translate Research Into Health Impact: A Systematic Review

Objective: To identify processes to engage stakeholders in healthcare Simulation Modeling (SM), and the impacts of this engagement on model design, model implementation, and stakeholder participants. To investigate how engagement process may lead to specific impacts. Data Sources: English-language articles on health SM engaging stakeholders in the MEDLINE, EMBASE, Scopus, Web of Science and Business Source Complete databases published from inception to February 2020. Study Design: A systematic review of the literature based on a priori protocol and reported according to PRISMA guidelines. Extraction Methods: Eligible articles were SM studies with a health outcome which engaged stakeholders in model design. Data were extracted using a data extraction form adapted to be specific for stakeholder engagement in SM studies. Data were analyzed using summary statistics, deductive and inductive content analysis, and narrative synthesis. Principal Findings: Thirty-two articles met inclusion criteria. Processes used to engage stakeholders in healthcare SM are heterogenous and often based on intuition rather than clear methodological frameworks. These processes most commonly involve stakeholders across multiple SM stages via discussion/dialogue, interviews, workshops and meetings. Key reported impacts of stakeholder engagement included improved model quality/accuracy, implementation, and stakeholder decision-making. However, for all but four studies, these reports represented author perceptions rather than formal evaluations incorporating stakeholder perspectives. Possible process enablers of impact included the use of models as "boundary objects" and structured facilitation via storytelling to promote effective communication and mutual understanding between stakeholders and modelers. Conclusions: There is a large gap in the current literature of formal evaluation of SM stakeholder engagement, and a lack of consensus about the processes required for effective SM stakeholder engagement. The adoption and clear reporting of structured engagement and process evaluation methodologies/frameworks are required to advance the field and produce evidence of impact.

A Pilot Digital Intervention Targeting Loneliness in Youth Mental Health

Background: Loneliness is an emerging issue for young people, but yet many interventions to address loneliness in this group focus on providing social opportunities. While these sorts of interventions may appear to increase social connections, loneliness is more related to quality rather than quantity of social relationships. Thus, interventions addressing loneliness should focus on maximizing the quality of current relationships. Together with youth consumers both with mental ill health and those without, we developed a digital smartphone application (app) called +Connect. The 6-week program delivers positive psychology content designed to improve relationship quality. We tested the acceptability, feasibility, and safety of the program in lonely young people with or without a mental health diagnosis of social anxiety disorder. We used a mixed method study design to triangulate pilot quantitative and qualitative data in young people with and without social anxiety disorder (SAD). Method: Nine participants with a diagnosis of social anxiety disorder (M _age = 21.00; SD = 1.41) and 11 participants with no mental health conditions (M _age = 20.36; SD = 2.16) completed the +Connect digital intervention. Results: Those with social anxiety disorder reported less acceptable ratings on outcomes. Feasibility ratings, measured by uptake and app completion, met a priori threshold criteria in both groups. Those with social anxiety disorder yielded more attrition, with almost double the attrition rate compared with those without the disorder. There were no safety issues elicited during the pilot study. In terms of outcomes, exploratory analyses indicated that the app itself is likely to be beneficial rather than cause harm. Our qualitative data indicated both groups reported no negative outcomes and noted that positive outcomes were driven by three processes: reflection, learning, and real-life application. Further exploratory data on usability indicated room for improvement in terms of giving more support for different components of the app (i.e., challenges). Conclusion: The pilot findings of this proof-of-concept app indicates some promise in terms of a second iterative version of +Connect.

Simulation Modeling for Psychiatric Service Planning: Protocol for a Mixed-Methods Study

Background

Mental health service managers must take into account multiple factors when making decisions about the best way to deliver care to clients across increasingly larger service areas. This task is made more difficult by the lack of evidence and tools historically available to inform these decisions. In recent decades, the increasing availability of epidemiological and service use data for mental illness has solved the problem of evidence, but there still exists a challenge to make these data easily accessible and understandable for managers.

Objective

This study aims to develop a simulation modeling tool to allow managers to explore various service configurations in virtual reality, enabling predictions to be made about the cost and quality of care.

Methods

This is a longitudinal, mixed-methods case study, comprising overlapping intervention and evaluation phases. In partnership with senior managers of a mental health program, the researchers will develop a series of simulation models in Arena to address key strategic issues facing the service. Thematic and content analyses of semistructured interviews, meeting observations, and document analysis will be used to evaluate the process of model implementation and the outcomes for both researchers and managers. The study is being conducted in Australia.

Results

Data collection has been ongoing since late 2013. To date, 3 prototype simulation models have been developed and presented to senior managers, and 18 evaluation interviews have been conducted. The project is expected to conclude in late 2018.

Conclusions

Findings of this study have the potential to shape decision making in mental health service delivery, by providing key examples of how to integrate patient data using simulation modeling. In addition, the results will provide key insights into how researchers and consultants can effectively implement simulation modeling in real-world health care organizations.

International Registered Report Identifier (IRRID)

RR1-10.2196/11119

Being pragmatic about healthcare complexity: our experiences applying complexity theory and pragmatism to health services research

BACKGROUND

The healthcare system has proved a challenging environment for innovation, especially in the area of health services management and research. This is often attributed to the complexity of the healthcare sector, characterized by intersecting biological, social and political systems spread across geographically disparate areas. To help make sense of this complexity, researchers are turning towards new methods and frameworks, including simulation modeling and complexity theory.

DISCUSSION

Herein, we describe our experiences implementing and evaluating a health services innovation in the form of simulation modeling. We explore the strengths and limitations of complexity theory in evaluating health service interventions, using our experiences as examples. We then argue for the potential of pragmatism as an epistemic foundation for the methodological pluralism currently found in complexity research. We discuss the similarities between complexity theory and pragmatism, and close by revisiting our experiences putting pragmatic complexity theory into practice.

CONCLUSION

We found the commonalities between pragmatism and complexity theory to be striking. These included a sensitivity to research context, a focus on applied research, and the valuing of different forms of knowledge. We found that, in practice, a pragmatic complexity theory approach provided more flexibility to respond to the rapidly changing context of health services implementation and evaluation. However, this approach requires a redefinition of implementation success, away from pre-determined outcomes and process fidelity, to one that embraces the continual learning, evolution, and emergence that characterized our project.

Interdevice reliability and validity assessment of the Nicholas Hand-Held Dynamometer

The Nicholas Hand-Held Dynamometer (HHD) has been shown to have excellent interday and intraday reliability when using the same HHD. Since clinics may have more than one HHD with which to evaluate patients, it would be of value to know if two identical HHDs measure the same variable consistently. The purpose of this investigation was to assess interdevice reliability of the Nicholas HHD as well as to determine its validity. Thirty healthy female subjects between the ages of 20 and 56 years (mean age = 28.4) were tested for hamstring strength. Three measurements of maximum hamstring contractions were obtained using the first HHD (Device A). The average of these three measurements was compared with the average of three measurements obtained after a brief rest using a second HHD (Device B). Measurements from the two HHDs were also compared with measurements obtained from a Kin-Com isokinetic dynamometer. The Kin-Com measurements were used as criteria to determine validity of the HHD. An intraclass correlation coefficient (ICC) calculated to determine reliability between the two HHDs was low (ICC = .58). Pearson product-moment correlation coefficients were calculated between the Kin-Com and each of the two HHDs. These values were .85 and .83 for Device A and B, respectively. Analysis of variance showed no significant difference between the Kin-Com and Device A but a significant difference between the Kin-Com and Device B (p < .001). Measurements obtained from two identical HHDs may be significantly different and should not be compared.

The influence of personal and collective self-esteem on strategies of social differentiation

The present study distinguished between personal self-esteem (PSE) and collective self-esteem (CSE) as determinants of in-group bias in an intergroup context. Subjects performed a group task, the product of which they subsequently evaluated ('own' group), along with solutions allegedly produced by another 'in-group' (similar nationality), and an 'out-group' (different nationality). This provided the opportunity for intragroup discrimination (own vs. in-group), and both direct (own vs. out-group) and indirect (in-group vs. out-group) strategies of intergroup discrimination. It was predicted that subjects high in CSE would differentiate more than subjects low in CSE, both directly and indirectly, but that intergroup discrimination would also result from high PSE. The relationship between the in-group and out-group was also manipulated by varying the salient out-group. It was predicted that subjects motivated to enhance social identity (high CSE) would differentiate more, directly and indirectly, when the out-group was seen as having a more competitive relationship with the in-group. Although this manipulation was unsuccessful, a follow-up suggested that the out-group predefined as less competitive was actually a more relevant comparison group in the context of the task, which is consistent with effects of this manipulation. Overall PSE and CSE were both found to influence differentiation at the intragroup and intergroup level, both independently and interactively. However, whereas high PSE led to greater positive differentiation, low CSE had this effect, and a combination of high PSE and low CSE produced the most consistent pattern of positive in-group differentiation across both out-group conditions. Possible mechanisms which account for this pattern are discussed and the relationship between dimensions of self-esteem and group differentiation is reappraised in the light of these findings.

The involvement of photosystem II-generated H2O2 in photoinhibition

The involvement of H2O2 generated by photosystem II (PSII) in the process of photoinhibition of thylakoids with a functional oxygen-evolving complex (OEC) was investigated. The rate of photoinhibition was decreased to the rate of loss of activity in the dark when bovine Fe-catalase was present during the photoinhibitory illumination. Photoinhibition was accelerated for both Cl(-)-depleted and Cl(-)-sufficient thylakoids when KCN was present to inhibit the thylakoid-bound Fe-catalase. We propose that these preparations become photoinhibited by reactions with H2O2 produced via oxidation of water by the Cl(-)-depleted OEC and by reduction of O2 at the QB site when PSII is illuminated without an electron acceptor.