Systematic review and meta-analysis of prognostic characteristics for breast cancers in populations with digital versus film mammography indicate the transition may have increased both early detection and overdiagnosis

OBJECTIVE

Film mammography has replaced digital mammography in breast screening programs globally. This led to a small increase in the rate of detection, but whether the detection of clinically important cancers increased is uncertain. We aimed to assess the impact on tumour characteristics of screen-detected and interval breast cancers.

STUDY DESIGN AND SETTING

We searched seven databases from inception to 08 October 2023 for publications comparing film and digital mammography within the same population of asymptomatic women at population (average) risk of breast cancer. We recorded reported tumour characteristics and assessed risk of bias using the ROBINS-I tool. We synthesized results using meta-analyses of random effects.

RESULTS

Eighteen studies were included in the analysis from 8 countries, including 11,592,225 screening examinations (8,117,781 film; 3,474,444 digital). There were no differences in tumour size, morphology, grade, node status, receptor status, or stage in the pooled differences for screen-detected and interval invasive cancer tumour characteristics. There were statistically significant increases in screen-detected DCIS across all grades: 0.05 (0.00-0.11), 0.14 (0.05-0.22), and 0.19 (0.05-0.33) per 1,000 screens for low, intermediate, and high grade DCIS respectively. There were similar (non-statistically significant) increases in screen-detected invasive cancer across all grades.

CONCLUSION

The increased detection of all grades of DCIS and invasive cancer may indicate both increased early detection of more aggressive disease and increased overdiagnosis.

FUNDING

Australian National Health and Medical Research Council and the National Breast Cancer Foundation.

REGISTRATION

PROSPERO 2017:CRD42017070601.

Breast cancer stage and size detected with film versus digital mammography in New South Wales, Australia: a population-based study using routinely collected data

Background Digital mammography has replaced film mammography in breast screening programs globally, including Australia. This led to an increase in the rate of detection, but whether there was increased detection of clinically important cancers is uncertain. Methods In this population-wide retrospective cohort study in New South Wales, Australia spanning 2004-2016 and including 4,631,656 screens, there were 22,965 cancers in women screened with film (n=11,040) or digital mammography (n=11,925). We examined the change in tumour characteristics overall and how these rates changed over time, accounting for changes in background rates using an interrupted time-series. Comparisons were made to unscreened women (n=26,326) during this time. Results We found increased detection of in-situ cancer (3.36 per 10,000 screens), localised invasive, and smaller-sized breast cancers attributable to the change in mammography technology, while screen-detected intermediate-sized and metastatic breast cancers decreased. Rates of early-stage and intermediate-sized interval cancers increased, and late-stage (-1.62 per 10,000 screens) and large interval cancers decreased. In unscreened women, there were small increases in the temporal trends of cancers across all stages. Conclusion At least some of the increased detection of smaller early-stage cancers may have translated into a reduction in larger and late-stage cancers, indicating beneficial detection of cancers that would have otherwise progressed. However, the increased detection of smaller early-stage and small cancers may also have increased overdiagnosis of lesions that would otherwise have not caused harm. Impact Robust evaluation of potential benefits and harms is needed after changes to screening programs.

Impact of policy changes of Medicare-rebated telehealth services on medical abortions provided at a family planning service during the coronavirus (COVID-19) pandemic

This study reviewed data on the mode of delivery of medical abortion care (via face-to-face or telehealth) at a Family Planning service during the coronavirus (COVID-19) pandemic; April 2020 to March 2022. This was considered over time, in the context of changing eligibility criteria for Medicare-rebated telehealth services as well as patient demographic data. The study demonstrated that when Medicare rebates for telehealth are available for all those requiring abortion care, telehealth contributes to care provision alongside face-to-face services, and is more likely to be utilised by people living in regional and remote areas.

Increased diagnosis of attention-deficit hyperactivity disorder despite stable hyperactive/inattentive behaviours: evidence from two birth cohorts of Australian children

BACKGROUND

Globally, ADHD diagnoses have increased substantially and there is concern that this trend does not necessarily reflect improved detection of cases but that overdiagnosis may be occurring. We directly compared ADHD diagnoses with ADHD-related behaviours and looked for changes across time among Australian children in a large, population-based prospective cohort study.

METHODS

We conducted a secondary analysis of the Longitudinal Study of Australian Children, including 4,699 children born 1999/2000 (cohort 1) and 4,425 children born 2003/2004 (cohort 2), followed from 4 to 13 years of age. We compared pre-diagnosis parent-reported hyperactive/inattentive behaviour scores between newly diagnosed (incident cases) and undiagnosed children and fitted Cox's proportional hazards regression models to examine the relationship between birth cohorts 1 and 2 and the risk of incident ADHD diagnosis.

RESULTS

Cumulative incident ADHD diagnoses increased from 4.6% in cohort 1 (born in 1999/2000) to 5.6% in cohort 2 (born in 2003/2004), while hyperactive/inattentive behaviour scores remained steady. Among ADHD diagnosed children, 26.5% (88/334) recorded pre-diagnosis behaviours in the normal range, 27.6% (n = 92) had borderline scores and 45.8% (n = 153) scored within the clinical range. Children born in 2003/2004 were more likely to be diagnosed with ADHD compared with those born in 1999/2000 (aHR = 1.33, 95% CI = 1.06-1.67, p = .012), regardless of their ADHD behaviour score (p = .972).

CONCLUSIONS

Diagnostic increases were not driven by rises in hyperactive/inattentive behaviours. A quarter of all children with an ADHD diagnosis recorded pre-diagnosis behaviours within the normal range. The increased likelihood of being diagnosed with ADHD for children from the later birth cohort was observed for children across the full range of ADHD-related behaviours.

Hypertensive retinopathy and cardiovascular disease risk: 6 population-based cohorts meta-analysis

Background

The cardiovascular risk associated with different levels of hypertensive retinopathy, including mild, remains unclear. We performed an individual participant meta-analysis from 6 population-based cohort studies to determine the relationship of hypertensive retinopathy with incident cardiovascular outcomes.

Methods

We identified cohort studies that objectively assessed hypertensive retinopathy from photographs, documented incident cardiovascular outcomes, and were population-based. Six studies contributed data from 11,013 individuals at baseline with 5-13 years follow-up. Participants were recruited if they had hypertension and did not have confounding conditions such as diabetic retinopathy. Main outcome measures were incident coronary heart disease (CHD), stroke and a composite endpoint of cardiovascular disease (CHD or stroke). Pooled estimates of incident risk ratios (IRR) were obtained after adjusting for age, gender, systolic blood pressure, serum total cholesterol, high density lipoprotein and smoking.

Results

Among eligible participants with hypertension and without diabetes, there were 1018/9662 (10.5%) incident CHD events, 708/11,013 (6.4%) incident stroke events and 1317/9378 (14.0%) incident CVD events. Mild hypertensive retinopathy was associated with increased risk of CVD (IRR 1.13, 95% CI 1.00 to 1.27) and CHD (IRR 1.17, 95% CI 1.02 to 1.34) but not stroke; moderate hypertensive retinopathy was associated with increased risk of CVD (IRR 1.25 95% CI 1.02 to 1.53) but not stroke or CHD individually.

Conclusions

In persons with hypertension, both mild and moderate hypertensive retinopathy were associated with higher CVD risk.

Using health administrative data to model associations and predict hospital admissions and length of stay for people with eating disorders

BACKGROUND

Eating disorders are serious mental illnesses requiring a whole of health approach. Routinely collected health administrative data has clinical utility in describing associations and predicting health outcome measures. This study aims to develop models to assess the clinical utility of health administrative data in adult eating disorder emergency presentations and length of stay.

METHODS

Retrospective cohort study on health administrative data in adults with eating disorders from 2014 to 2020 in Sydney Local Health District. Emergency and admitted patient data were collected with all clinically important variables available. Multivariable regression models were analysed to explore associations and to predict admissions and length of stay.

RESULTS

Emergency department modelling describes some clinically important associations such as decreased odds of admission for patients with Bulimia Nervosa compared to Anorexia Nervosa (Odds Ratio [OR] 0.31, 95% Confidence Interval [95%CI] 0.10 to 0.95; p = 0.04). Admitted data included more predictors and therefore further significant associations including an average of 0.96 days increase in length of stay for each additional count of diagnosis/comorbidities (95% Confidence Interval [95% CI] 0.37 to 1.55; p = 0.001) with a valid prediction model (R² = 0.56).

CONCLUSIONS

Health administrative data has clinical utility in adult eating disorders with valid exploratory and predictive models describing associations and predicting admissions and length of stay. Utilising health administrative data this way is an efficient process for assessing impacts of multiple factors on patient care and predicting health care outcomes.

Pathways to IUD and implant insertion in general practice: a secondary analysis of the ACCORd study

BACKGROUND

Despite recommendations, long-acting reversible contraceptives (LARC) are not always offered as first-line contraceptives in general practice. This study aimed to describe pathways used by women for insertion of LARC.

METHODS

This is a secondary analysis of data from the Australian Contraceptives ChOice pRoject (ACCORd), a cluster randomised controlled trial set in 57 general practices in Melbourne, Australia. We investigated whether an educational intervention for general practitioners (GPs) and a rapid LARC insertion clinic increased LARC uptake. The main outcome measures were the type of health service, location/provider of intrauterine device (IUD) insertion; time to insertion; and distance travelled for IUD insertion.

RESULTS

During ACCORd, 149 women had LARC insertion. IUD training was reported by 37% of GPs, but only 12% inserted them. In contrast, 70% of GPs inserted implants and 95% of women accessed implant insertion through their own general practice. LARC rapid referral clinics were used by 52% (13/25) of intervention GPs, where 71% (41/56) of IUD insertions occurred in these clinics (but no implants). There was no difference in the mean time from referral to IUD insertion between women attending intervention and control GPs (mean days 37.6vs 32.7; P=0.61). GPs (including IUD inserters) used a variety of referral pathways for IUD insertion, including public and private clinics, and other GPs. Women travelled up to 90km for IUD insertion.

CONCLUSIONS

Although implant insertion has been integrated into general practice, few GPs insert IUDs. Where the option exists for GPs to refer to a LARC rapid referral clinic, the majority of IUD insertions will take place there. Establishing a network of such clinics Australia wide may both increase IUD uptake and address the extensive need for GP training in IUD insertion.

Carer preparedness improved by providing a supportive educational intervention for carers of patients with high-grade glioma: RCT results

BACKGROUND

High-grade glioma (HGG) is a rapidly progressing and debilitating disease. Family carers take on multiple responsibilities and experience high levels of distress. We aimed to deliver a nurse-led intervention (Care-IS) to carers to improve their preparedness to care and reduce distress.

METHODS

We conducted a randomised controlled trial (ACTRN:12612001147875). Carers of HGG patients were recruited during patients' combined chemoradiation treatment. The complex intervention comprised four components: (1) initial telephone assessment of carer unmet needs; (2) tailored hard-copy resource folder; (3) home visit; and, (4) monthly telephone support for up to 12 months. Primary outcomes included preparedness for caregiving and distress at 2, 4, 6 and 12 months. Intervention effects were estimated using linear mixed models which included a time by group interaction. Secondary outcomes included anxiety, depression, quality of life, carer competence and strain.

RESULTS

We randomised 188 carers (n = 98 intervention, n = 90 control). The intervention group reported significantly higher preparedness for caregiving at 4 months (model β = 2.85, 95% CI 0.76-4.93) and all follow-up timepoints including 12 months (model β = 4.35, 95% CI 2.08-6.62), compared to the control group. However, there was no difference between groups in carer distress or any secondary outcomes.

CONCLUSIONS

This intervention was effective in improving carer preparedness. However, carer distress was not reduced, potentially due to the debilitating/progressive nature of HGG and ongoing caring responsibilities. Future research must explore whether carer interventions can improve carer adjustment, self-efficacy and coping and how we support carers after bereavement. Additionally, research is needed to determine how to implement carer support into practice.

Increasing the availability of long-acting reversible contraception and medical abortion in primary care: the Australian Contraception and Abortion Primary Care Practitioner Support Network (AusCAPPS) cohort study protocol

INTRODUCTION

Although primary care practitioners are the main providers of long-acting reversible contraception (LARC) and early medical abortion (EMA) in Australia, few provide these services. A professional community of practice (CoP) has the potential to improve LARC and EMA provision through evidence-based guidance, expert support and peer-to-peer engagement.The primary objective is to establish, implement and evaluate an innovative, multidisciplinary online CoP (AusCAPPS Network) to increase LARC and EMA services in Australian primary care. Secondary objectives are to (1) increase the number of general practitioners (GPs) and pharmacists certified to provide or dispense EMA, respectively, (2) increase LARC and EMA prescription rates and, (3) improve primary care practitioners' knowledge, attitudes and provision of LARC and EMA.

METHODS AND ANALYSIS

A stakeholder knowledge exchange workshop (KEW) will be conducted to inform the AusCAPPS Network design. Once live, we aim to reach 3000 GPs, practice nurses and community pharmacists members. Changes in the number of GPs and pharmacists certified to provide or dispense EMA, respectively, and changes in the number of LARCs and EMAs prescribed will be gleaned through health service data. Changes in the knowledge attitudes and practices will be gleaned through an online survey with 500 individuals from each professional group at baseline and 12 months after members have joined AusCAPPs; and experiences of the AusCAPPS Network will be evaluated using interviews with the project team plus a convenience sample of 20 intervention participants from each professional group. The project is underpinned by the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, and a realist framework will inform analysis.

ETHICS AND DISSEMINATION

Ethical approval was received from the Monash University Human Research Ethics Committee (No. 28002). Dissemination will occur through KEWs, presentations, publications and domestic and international networks.

TRIAL REGISTRATION NUMBER

ACTRN12622000655741.

Considerations for Evaluating the Introduction of New Cancer Screening Technology: Use of Interval Cancers to Assess Potential Benefits and Harms

This framework focuses on the importance of the consideration of the downstream intermediate and long-term health outcomes when a change to a screening program is introduced. The authors present a methodology for utilising the relationship between screen-detected and interval cancer rates to infer the benefits and harms associated with a change to the program. A review of the previous use of these measures in the literature is presented. The framework presents other aspects to consider when utilizing this methodology, and builds upon an existing framework that helps researchers, clinicians, and policy makers to consider the impacts of changes to screening programs on health outcomes. It is hoped that this research will inform future evaluative studies to assess the benefits and harms of changes to screening programs.

Association of Attention-Deficit/Hyperactivity Disorder Diagnosis With Adolescent Quality of Life

IMPORTANCE

Appropriate diagnosis of attention-deficit/hyperactivity disorder (ADHD) can improve some short-term outcomes in children and adolescents, but little is known about the association of a diagnosis with their quality of life (QOL).

OBJECTIVE

To compare QOL in adolescents with and without an ADHD diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study followed an emulated target trial design using prospective, observational data from the Longitudinal Study of Australian Children, a representative, population-based prospective cohort study with biennial data collection from 2006 to 2018 with 8 years of follow-up (ages 6-7 to 14-15 years). Propensity score matching was used to ensure children with and without ADHD diagnosis were well matched on a wide range of variables, including hyperactive/inattentive (H/I) behaviors. Eligible children were born in 1999 to 2000 or 2003 to 2004 and did not have a previous ADHD diagnosis. All incident ADHD cases were matched with controls. Data were analyzed from July 2021 to January 2022.

EXPOSURES

Incident parent-reported ADHD diagnosis at age 6 to 7, 8 to 9, 10 to 11, 12 to 13, or 14 to 15.

MAIN OUTCOMES AND MEASURES

Quality of life at age 14 to 15 was measured with Child Health Utility 9D (CHU9D) and 8 other prespecified, self-reported measures mapped to the World Health Organization's QOL domains. Pooled regression models were fitted for each outcome, with 95% CIs and P values calculated using bootstrapping to account for matching and repeat observations.

RESULTS

Of 8643 eligible children, a total of 393 adolescents had an ADHD diagnosis (284 [72.2%] boys; mean [SD] age, 10.03 [0.30] years; mean [SD] H/I Strengths and Difficulties Questionnaire score, 5.05 [2.29]) and were age-, sex-, and H/I score-matched with 393 adolescents without ADHD diagnosis at time zero. Compared with adolescents without diagnosis, those with an ADHD diagnosis reported similar QOL on CHU9D (mean difference, -0.03; 95% CI, -0.07 to 0.01; P = .10), general health (mean difference, 0.11; 95% CI, -0.04 to 0.27; P = .15), happiness (mean difference, -0.18; 95% CI, -0.37 to 0.00; P = .05), and peer trust (mean difference, 0.65; 95% CI, 0.00 to 1.30; P = .05). Diagnosed adolescents had worse psychological sense of school membership (mean difference, -2.58; 95% CI, -1.13 to -4.06; P < .001), academic self-concept (mean difference, -0.14; 95% CI, -0.02 to -0.26; P = .02), and self-efficacy (mean difference, -0.20; 95% CI, -0.05 to -0.33; P = .007); displayed more negative social behaviors (mean difference, 1.56; 95% CI, 0.55 to 2.66; P = .002); and were more likely to harm themselves (odds ratio, 2.53; 95% CI, 1.49 to 4.37; P < .001) than adolescents without diagnosis.

CONCLUSIONS AND RELEVANCE

In this cohort study, ADHD diagnosis was not associated with any self-reported improvements in adolescents' QOL compared with adolescents with similar levels of H/I behaviors but no ADHD diagnosis. ADHD diagnosis was associated with worse scores in some outcomes, including significantly increased risk of self-harm. A large, randomized clinical trial with long-term follow-up is needed.

The preferences of women in Australia for the features of long-acting reversible contraception: results of a discrete choice experiment

PURPOSE

Long-acting reversible contraceptives (LARC), such as intrauterine devices (IUD) and implants, are highly effective. However, the uptake of LARC in Australia has been slow and the oral contraceptive pill (OC) remains the best known and most widely used contraceptive. Our aim was to investigate women's preferences for the features of LARC.

METHODS

We used a discrete choice experiment (DCE) in which each respondent completed 12 choice tasks. We recruited a general population sample of 621 women in Australia aged 18-49 using an online survey panel. A mixed logit model was used to analyse DCE responses; a latent class model explored preference heterogeneity.

RESULTS

Overall, 391 (63%) of women were currently using contraception; 49.3% were using an OC. About 22% of women were using a LARC. Women prefer products that are more effective in preventing pregnancy, have low levels of adverse events (including negative effects on mood), and which their general practitioner (GP) recommends or says is suitable for them.

CONCLUSIONS

Women have strong preferences for contraceptive products that are effective, safe, and recommended by their GP. The results indicate which characteristics of LARCs need to be front and centre in information material and in discussions between women and healthcare professionals.

Sustainable and effective methods to increase long-acting reversible contraception uptake from the ACCORd general practice trial

OBJECTIVE

Most Australian women access contraception through general practitioners (GPs) but choose oral methods rather than long-acting reversible contraceptives (LARCS). The Australian Contraceptive ChOice pRoject (ACCORd) successfully tested a complex intervention for LARC uptake. We aimed to explore the critical elements of this intervention to increase LARC uptake.

DESIGN

ACCORd was a cluster randomised control trial conducted in 57 GP clinics in Melbourne, Australia. To explore intervention impact, fidelity checks (n=21 GPs) and interviews with 37 GPs and 40 patients were undertaken 12 months after initial consultations. Data were inductively coded, thematically analysed and mapped to Normalization Process Theory constructs.

RESULTS

Doctors understood the importance of effectiveness-based contraceptive counselling (EBCC). GPs demonstrated cognitive engagement in the promotion of LARC and some appreciated the rapid referral pathways. GPs and women valued the effectiveness approach. GPs held varying views about having a rapid referral pathway, with many already having established pathways in place. Some GPs viewed intrauterine device insertion costs or insertion training as barriers to ongoing practice. Most GPs and women saw the ACCORD model as effective and sustainable.

CONCLUSIONS

GP training in EBCC and the use of rapid referral pathways were critical features of an effective sustainable model for successful uptake of LARCs in primary care.

IMPLICATIONS FOR PUBLIC HEALTH

Improving Australian women's access to and use of LARCs is sustainable with EBCC training and support for general practitioners.

Sexual Difficulties, Problems, and Help-Seeking in a National Representative Sample: The Second Australian Study of Health and Relationships

The Australian Study of Health and Relationships is a large national population-representative survey of sexual behavior and attitudes conducted every decade. We describe experiences of sexual difficulties lasting at least a month among Australians surveyed in 2012-2013 and identify changes since the previous survey in 2001-2002. Computer-assisted telephone interviews were completed by 20,091 people aged 16-69 years (participation rate 66%) of whom 16,897 people had had sex with a partner in the previous year. We asked how long each difficulty lasted, whether it was a problem, and whether they sought treatment. Half (48%) the men and 68% of women reported at least one difficulty. Lack of interest in having sex was common (28% men, 52% women); 21% of men reported coming to orgasm "too quickly" and women reported inability to reach orgasm (25%) and trouble with vaginal dryness (22%). Women were more likely than men not to find sex pleasurable and to have physical pain during intercourse. Some differences by age group were also apparent. Many difficulties were not seen as problems, especially lacking interest and reaching orgasm too quickly. People with erection/dryness problems, or with pain in intercourse, were more likely to seek treatment, as were people with multiple difficulties. Between 2001-2002 and 2012-2013, there was little change for men, but among women rates of all sexual difficulties fell by 4-10 percentage points. This change accompanied a drop in frequency of sex among people in ongoing relationships and an increase in masturbation and use of pornography. One explanation might be that, over time, fewer women were agreeing to "service sex" when they were not in the mood. Overall, the drop in prevalence of women's sexual difficulties since a decade earlier suggests a change towards more egalitarian sexual relations.

A Prospective Longitudinal Study of Health-Related Quality of Life and Psychological Wellbeing after an Implantable Cardioverter Defibrillator in Patients with Genetic Heart Diseases

Background

Genetic heart diseases (GHDs) can be clinically heterogeneous and pose an increased risk of sudden cardiac death (SCD). The implantable cardioverter-defibrillator (ICD) is a lifesaving therapy. Impacts on prospective and long-term psychological and health-related quality of life (HR-QoL) after ICD implant in patients with GHDs are unknown.

Objectives

Investigate the psychological functioning and HR-QoL over time in patients with GHDs who receive an ICD, and identify risk factors for poor psychological functioning and HR-QoL.

Methods

A longitudinal, prospective study design was used. Patients attending a specialized clinic, diagnosed with a GHD for which they received an ICD between May 2012 and January 2015, were eligible. Baseline surveys were completed prior to ICD implantation with 5-year follow-up after ICD implant. We measured psychological functioning (Hospital Anxiety Depression Scale, Florida Shock Anxiety Scale), HR-QoL (Short-Form 36v2), and device acceptance (Florida Patient Acceptance Scale).

Results

Forty patients were included (mean age 46.3 ± 14.2 years; 65.0% male). Mean psychological and HR-QoL measures were within normative ranges during follow-up. After 12 months, 33.3% and 19.4% of participants showed clinically elevated levels of anxiety and depression, respectively. Longitudinal mixed-effect analysis showed significant improvements from baseline to first follow-up for the overall cohort, with variability increasing after 36 months. Nontertiary education and female sex predicted worse mental HR-QoL and anxiety over time, while comorbidities predicted depression and worse physical HR-QoL.

Conclusion

While the majority of patients with a GHD adjust well to their ICD implant, a subset of patients experience poor psychological and HR-QoL outcomes.

Cost-effectiveness of a complex intervention in general practice to increase uptake of long-acting reversible contraceptives in Australia

Objective The aim of this study was to evaluate the cost-effectiveness of the Australian Contraceptive ChOice pRoject (ACCORd) intervention. Methods An economic evaluation compared the costs and outcomes of the ACCORd intervention with usual care (UC). Data from the ACCORd trial were used to estimate costs and efficacy in terms of contraceptive uptake and quality of life. Rates of contraceptive failure and pregnancy were sourced from the literature. Using a Markov model, within-trial results were extrapolated over 10 years and subjected to univariate sensitivity analyses. Model outputs were expressed as the cost per quality-adjusted life years (QALY) gained and cost per unintended pregnancy resulting in birth (UPB) avoided. Results Over 10 years, compared with UC, initiating contraception through the ACCORd intervention resulted in 0.02 fewer UPB and higher total costs (A$2505 vs A$1179) per woman. The incremental cost-effectiveness of the ACCORd intervention versus UC was A$1172 per QALY gained and A$7385 per UPB averted. If the start-up cost of the ACCORd intervention was removed, the incremental cost-effectiveness ratio was A$81 per QALY gained and A$511 per UPB averted. The results were most sensitive to the probability of contraceptive failure, the probability of pregnancy-related healthcare service utilisation or the inclusion of the costs of implementing the ACCORd intervention. Conclusions From a health system perspective, if implemented appropriately in terms of uptake and reach, and assuming an implicit willingness to pay threshold of A$50 000 the ACCORd intervention is cost-effective. What is known about the topic? The uptake of long-active reversible contraceptives (LARC) in Australia is low. The ACCORd trial assessed the efficacy of providing structured training to general practitioners (GPs) on LARC counselling, together with access to rapid referral to insertion clinics. What does this paper add? This study is the first to assess the cost-effectiveness of a complex intervention in the general practice setting aimed at increasing the uptake of LARC in Australia. What are the implications for practitioners? The results show that implementing a complex intervention in general practice involving GP education and the availability of rapid referral to LARC insertion clinics is a cost-effective approach to increase LARC use and its attending efficacy. If the majority of Australian GPs were able to deliver effectiveness-based contraceptive counselling and either insert LARC or use a rapid referral process to a LARC insertion clinic, the additional cost associated with the purchase of LARC products and their insertion would be offset by reductions to health system costs as a result of fewer UPB and abortions. Moreover, the benefits to women's physical and psychological health of avoiding such events is substantial.

Australian primary health care nurses

Preconception care (PCC) entails counselling and interventions to optimise health before pregnancy. Barriers to this service delivery include access and time. Primary healthcare nurses (PHCNs) are uniquely placed to deliver PCC. The aim of this study was to understand PHCNs' knowledge, practice and attitudes to PCC. A cross-sectional study was performed of a convenience sample of PHCNs in Australia who were seeing people of reproductive age. Recruitment was via the Australian Primary Health Care Nurses Association (APNA) electronic communication platforms. The 18-item, online, anonymous survey captured demographics, as well as PCC knowledge, practices and attitudes. Descriptive statistics were used to describe our findings. In all, 152 completed surveys were received. Of all respondents, 74% stated they discuss PCC in their practice, although only 13% do so routinely. Of these, more preconception discussions are held with women than with men. In total, 95% of respondents identified at least one barrier to delivery of PCC, with lack of time and knowledge being the most common. The findings of this study can inform targeted strategies, including education programs and resources, and consideration of incentives to support PHCNs deliver PCC. This study identifies areas for improvement at the individual, organisational and health system levels to enhance the role of PHCNs in PCC.

Effect of a School-Based Educational Intervention About the Human Papillomavirus Vaccine on Psychosocial Outcomes Among Adolescents: Analysis of Secondary Outcomes of a Cluster Randomized Trial

IMPORTANCE

Delivery of vaccination to adolescents via a school-based program provides an opportunity to promote their involvement in health decision-making, service provision, and self-efficacy (belief in one's ability to perform a certain behavior).

OBJECTIVE

To examine the effect of a human papillomavirus (HPV) vaccination education and logistical intervention on adolescent psychosocial outcomes.

DESIGN, SETTING, AND PARTICIPANTS

In this cluster randomized trial and process and qualitative evaluation, adolescents aged 12 to 13 years (first year of high school) were recruited at high schools in Western Australia (WA) and South Australia (SA) in 2013 and 2014. Statistical analysis was performed from January 2016 to December 2020.

INTERVENTIONS

The complex intervention consisted of an adolescent intervention to promote knowledge and psychosocial outcomes, shared decisional support tool, and logistical strategies.

MAIN OUTCOMES AND MEASURES

Prespecified secondary outcomes were assessed. The HPV Adolescent Vaccination Intervention Questionnaire (HAVIQ) was used to measure changes in adolescent knowledge (6-item subscale), fear and anxiety (6-item subscale), self-efficacy (5-item subscale), and decision-making (8-item subscale). The hypothesis was that the intervention would improve adolescent involvement in vaccine decision-making (measured before dose 1 only), improve vaccine-related self-efficacy, and reduce vaccine-related fear and anxiety (measured before doses 1, 2, and 3). Mean (SD) scores for each subscale were compared between intervention and control students. In the process evaluation, focus groups were conducted. Analyses of the HAVIQ data were conducted from 2016 to 2020. Qualitative analyses of the focus groups were undertaken from 2017 to 2020.

RESULTS

The trial included 40 schools (21 intervention and 19 control) across sectors with 6967 adolescents (mean [SD] age, 13.70 [0.45] years). There were 3805 students (1689 girls and 2116 boys) in the intervention group and 3162 students (1471 girls and 1691 boys) in the control group. The overall response rate for the HAVIQ was 55%. In WA, where parental consent was required, the response rate was 35% (1676 of 4751 students); in SA, where parental consent was not required, it was 97% (2166 of 2216 students). The mean (SD) score for decision-making in the intervention group before dose 1 was 3.50 (0.42) of 5 points and 3.40 (0.40) in the control group, a small but significant difference of 0.11 point (95% CI, 0.06 to 0.16 point; P < .001). There was a small difference in favor of the intervention group in reduced vaccination-related anxiety (pre-dose 1 difference, -0.11 point [95% CI, -0.19 to -0.02 point]; pre-dose 2 difference, -0.18 point [95% CI, -0.26 to -0.10 point]; pre-dose 3 difference, -0.18 [95% CI, -0.24 to -0.11]) and increased vaccination self-efficacy (pre-dose 1 difference, 4.0 points; [95% CI, 1.0 to 7.0 points]; pre-dose 2 difference, 4.0 points [95% CI, 2.0 to 6.0 points]; pre-dose 3 difference, 3.0 points [95% CI, 1.0 to 5.0 points]). Focus group data from 111 adolescents in 6 intervention and 5 control schools revealed more confidence and less anxiety with each vaccine dose.

CONCLUSIONS AND RELEVANCE

In this cluster randomized trial, there was a small difference in adolescent decisional involvement and vaccine-related confidence and reduced vaccination-related fear and anxiety that was maintained throughout the vaccine course in the intervention vs control groups. Guidelines for vaccination at school should incorporate advice regarding how this outcome can be achieved.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: ACTRN12614000404628.

Early medical abortion services provided in Australian primary care

OBJECTIVES

To examine primary care provision of early medical abortion services in Australia.

DESIGN

Cross-sectional study; analysis of Pharmaceutical Benefits Scheme (PBS) dispensing data.

SETTING, PARTICIPANTS

Women of child-bearing age (15-54 years), Australia, 2015-2019.

MAIN OUTCOME MEASURES

Age-standardised rates of MS-2 Step prescriptions dispensed by year for 2015-2019, and age-standardised rates by state, remoteness area, and level 3 statistical areas (SA3s) for 2019. Numbers and proportions of SA3s in which MS-2 Step was not prescribed by a GP or dispensed by a community pharmacy during 2019 (unweighted and weighted by number of women of reproductive age), by state and remoteness area.

RESULTS

During 2015-2019, 91 643 PBS prescriptions for MS-2 Step were dispensed; the national age-standardised rate increased from 1.63 in 2015 to 3.79 prescriptions per 1000 women aged 15-54 years in 2019. In 2019, rates were higher in outer regional Australia (6.53 prescriptions per 1000 women aged 15-54 years) and remote Australia (6.02 per 1000) than in major cities (3.30 per 1000). However, about 30% of women in Australia lived in SA3s in which MS-2 Step had not been prescribed by a GP during 2019, including about 50% of those in remote Australia.

CONCLUSIONS

The rate of early medical abortion is greater among women in remote, outer regional, and inner regional Australia than in major cities, but a considerable proportion of women live in areas in which MS-2 Step was not locally prescribed or dispensed during 2019. Supporting GPs in the delivery of early medical abortion services locally should be a focus of health policy.

Outcomes of routine screening for reproductive coercion in a family planning service

Background Reproductive coercion (RC) occurs when a person's autonomous decision-making regarding reproductive health is compromised by another. RC screening, that is, the use of routine, non-invasive screening questions asked of service users/clients, is one strategy that can be used to assess for RC. Routine screening for RC was implemented within Family Planning NSW clinical consultations in December 2018. A cross-sectional study was undertaken to review the outcomes of screening to better understand the situation of RC among women accessing family planning services. Methods A retrospective review of clinical consultation data of eligible women attending Family Planning NSW clinics in 2019 was undertaken. Descriptive analysis was conducted and modified Poisson regression was used to estimate prevalence ratios and assess associations between binary outcomes and client characteristics. Results Of 7943 women eligible for RC screening, 5497 were screened (69%) and 127 women (2.3%) disclosed RC. RC was more likely to be disclosed among clients who were unemployed, had a disability or had more than one visit within 1 year. Conclusions Sexual and reproductive health clinicians, in particular, are well placed to conduct RC screening. However, they must have adequate training and access to resources to implement screening and respond to women who disclose RC.

Reproductive experiences and outcomes among a representative sample of women: the Second Australian Study of Health and Relationships

OBJECTIVE

To enumerate pregnancy outcomes for a representative sample of women in Australia surveyed in 2012-2013 (primary aim) and compare these with women surveyed in 2001-2002 (secondary aim).

METHODS

Computer-assisted telephone interviews with over 10,000 women aged 16-69 years (participation rate 68.4%). Results are weighted for chance of selection and to reflect the population as a whole.

RESULTS

Of women with experience of vaginal intercourse, 75.1% had ever been pregnant, 18.4% reported difficulties getting pregnant and 10.0% had had fertility treatment. Of those who had been pregnant, 91.3% had ever had a live birth, 34.3% a miscarriage, 22.8% an abortion and 2.3% a stillbirth; 0.9% had relinquished a child for adoption. The proportion first pregnant in their 30s was 11% among women aged 60-69 and 26% among those aged 40-49. Fewer older women reported difficulties getting pregnant. Of the 21,882 pregnancies reported, 70% led to live births and 10% were terminated. Compared with our 2001-2002 survey, fewer women reported ever having been pregnant. Giving up newborns for adoption has become very rare.

CONCLUSIONS

Falling fertility since the 1960s reflects greater access to contraception and abortion and higher opportunity costs of childbearing. Implications for public health: These findings on women's lifetime reproductive experiences complement routine annual data collections.

Transverse position. Using rotation to aid normal birth-OUTcomes following manual rotation (the TURN-OUT trial): a randomized controlled trial

BACKGROUND

The fetal occiput transverse position in the second stage of labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation in the second stage of labor is considered a safe and easy to perform procedure that has been used to prevent operative deliveries.

OBJECTIVE

This study aimed to determine the efficacy of prophylactic manual rotation in the management of the occiput transverse position for preventing operative delivery. We hypothesized that among women who are at ≥37 weeks' gestation with a baby in the occiput transverse position early in the second stage of labor, manual rotation compared with a "sham" rotation will reduce the rate of operative delivery.

STUDY DESIGN

A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 3 tertiary hospitals was conducted in Australia. The primary outcome was operative (cesarean, forceps, or vacuum) delivery. Secondary outcomes were cesarean delivery, serious maternal morbidity and mortality, and serious perinatal morbidity and mortality. Outcomes were analyzed by intention to treat. Proportions were compared using χ² tests adjusted for stratification variables using the Mantel-Haenszel method or Fisher exact test. Planned subgroup analyses by operator experience and technique of manual rotation (digital or whole hand rotation) were performed. The planned sample size was 416 participants (trial registration: ACTRN12613000005752).

RESULTS

Here, 160 women with a term pregnancy and a baby in the occiput transverse position in the second stage of labor, confirmed by ultrasound, were randomly assigned to receive either a prophylactic manual rotation (n=80) or a sham procedure (n=80), which was less than our original intended sample size. Operative delivery occurred in 41 of 80 women (51%) assigned to prophylactic manual rotation and 40 of 80 women (50%) assigned to a sham rotation (common risk difference, -4.2% [favors sham rotation]; 95% confidence interval, -21 to 13; P=.63). Among more experienced proceduralists, operative delivery occurred in 24 of 47 women (51%) assigned to manual rotation and 29 of 46 women (63%) assigned to a sham rotation (common risk difference, 11%; 95% confidence interval, -11 to 33; P=.33). Cesarean delivery occurred in 6 of 80 women (7.5%) in the manual rotation group and 7 of 80 women (8.7%) in the sham group. Instrumental (forceps or vacuum) delivery occurred in 35 of 80 women (44%) in the manual rotation group and 33 of 80 women (41%) in the sham group. There was no significant difference in the combined maternal and perinatal outcomes. The trial was terminated early because of limited resources.

CONCLUSION

Planned prophylactic manual rotation did not result in fewer operative deliveries. More research is needed in the use of manual rotation from the occiput transverse position for preventing operative deliveries.

Fertility Preferences, Contraceptive Use, and the Unmet Need for Contraception in Papua New Guinea: Key Findings From 1996 to 2016

Expanding access to reliable contraception is a global priority in the fight to lower maternal morbidity and mortality. Papua New Guinea (PNG) continues to face significant challenges in enhancing contraceptive services for women. PNG Demographic Health Survey (DHS) has been undertaken every 10 years since 1996 and describes the major trends in crude birth rates, fertility rates and preferences, contraceptive use, and the unmet needs for contraception. The latest survey in 2016 means that there are now 20 years of data available. Between 1996 and 2016, modern contraceptive prevalence increased from 14% to 29% with a preference for longer acting reversible contraception, though the unmet need for contraception persisted at 32% with minimal change since 1996. Rurally dwelling women as well as those with low literacy, who make up the majority of reproductive age women in PNG, were consistently the least likely to use contraception. Expanding access to reliable contraception should therefore be prioritized for these women.

Management of heavy menstrual bleeding in Australian general practice: An analysis of BEACH data

BACKGROUND AND OBJECTIVES

The 'Heavy menstrual bleeding (HMB) clinical care standard' was released in October 2017. The aim of this study was to determine the rate and management of HMB by Australian general practitioners (GPs) prior to release of the Standard.

METHOD

Data collected between April 2000 to March 2016 (inclusive) in the Bettering the Evaluation and Care of Health program were analysed for HMB management.

RESULTS

The rate at which GPs managed HMB increased over the study period. The combined oral contraceptive pill was the most frequently prescribed treatment, except among women aged 45-54 years. There were low prescribing/insertion rates of the levonorgestrel intrauterine system (LNG-IUS) for women aged 25-54 years, and none for patients aged 12-24 years.

DISCUSSION

Improved understanding of patient and GP perspectives, and further education and training, could increase use of the LNG-IUS and other pharmaceutical treatments where appropriate, as recommended by the HMB clinical care standard.

Influences on condom use: A secondary analysis of women's perceptions from the Australian Contraceptive ChOice pRoject (ACCORd) trial

BACKGROUND AND OBJECTIVES

Women's ability to negotiate condom use helps prevent sexually transmissible infections (STIs) and unintended pregnancies. The aim of this study was to assess the relationship between substance use, risk perception and the certainty of using condoms in several hypothetical situations.

METHOD

This is a secondary analysis from the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial. Descriptive statistics and logistic regression were used for the analysis.

RESULTS

At baseline, contraceptive questions were answered by 698 women attending 57 general practices in Melbourne, Australia. Condom use was reported by 47%. Of those using condoms as the sole form of contraception (n = 137), 20% used them inconsistently. Dual protection was used by 58% of women (188/325). Condoms and the pill were more frequently used than condoms and longer-acting contraceptives. Women were less likely to be confident negotiating condom use when using substances.

DISCUSSION

Substance use and the concurrent use of other forms of contraception impact use of condoms. Even when condoms are the sole form of contraception with willing partners, use is inconsistent, leaving women at risk of pregnancy and STI.

To what extent do postpartum contraception policies or guidelines exist in Australia and New Zealand: A document analysis study

Women are susceptible to unintended, rapid repeat pregnancies in the first 12 months postpartum. Access to postpartum contraception, specifically long-acting reversible contraception, enables better planning of pregnancy timing and spacing and allows optimisation of health before the next conception. Clinical Practice Guidelines (CPG), and implementation policies, supported by consumer input, can improve such access. We searched publicly available Australian and New Zealand guidelines and policy documents addressing postpartum contraception. One CPG detailed specific information about postpartum contraception and, although of high quality, requires modification to local contexts to support implementation and policy development.

Impact of Full-Field Digital Mammography Versus Film-Screen Mammography in Population Screening: A Meta-Analysis

BACKGROUND

Breast screening programs replaced film mammography with digital mammography, and the effects of this practice shift in population screening on health outcomes can be measured through examination of cancer detection and interval cancer rates.

METHODS

A systematic review and random effects meta-analysis were undertaken. Seven databases were searched for publications that compared film with digital mammography within the same population of asymptomatic women and reported cancer detection and/or interval cancer rates.

RESULTS

The analysis included 24 studies with 16 583 743 screening examinations (10 968 843 film and 5 614 900 digital). The pooled difference in the cancer detection rate showed an increase of 0.51 per 1000 screens (95% confidence interval [CI] = 0.19 to 0.83), greater relative increase for ductal carcinoma in situ (25.2%, 95% CI = 17.4% to 33.5%) than invasive (4%, 95% CI = -3% to 13%), and a recall rate increase of 6.95 (95% CI = 3.47 to 10.42) per 1000 screens after the transition from film to digital mammography. Seven studies (80.8% of screens) reported interval cancers: the pooled difference showed no change in the interval cancer rate with -0.02 per 1000 screens (95% CI = -0.06 to 0.03). Restricting analysis to studies at low risk of bias resulted in findings consistent with the overall pooled results for all outcomes.

CONCLUSIONS

The increase in cancer detection following the practice shift to digital mammography did not translate into a reduction in the interval cancer rate. Recall rates were increased. These results suggest the transition from film to digital mammography did not result in health benefits for screened women. This analysis reinforces the need to carefully evaluate effects of future changes in technology, such as tomosynthesis, to ensure new technology leads to improved health outcomes and beyond technical gains.

Current contraceptive use in women with a history of unintended pregnancies: Insights from the Australian Contraceptive ChOice pRoject (ACCORd) trial

BACKGROUND AND OBJECTIVES

Clinical guidelines advocate using long-acting reversible contraceptives (LARC) to reduce unintended pregnancy, but LARC use in Australia is poor. Additionally, little is known about contraceptive practices of women with a history of unintended pregnancy. The aim of this study was to describe current contraception use according to a history of unintended pregnancy.

METHOD

Data were analysed from women recruited into The Australian Contraceptive ChOice pRoject (ACCORd) trial.

RESULTS

Approximately 47% (128/275) of women aged 16-45 years reported unintended pregnancies, and 30% had an abortion (83/275). Contraceptive data available from 117 women showed that condoms (24%, n = 28/117) and the oral contraceptive pill (22%, n = 26/117) were most commonly used among women reporting one unintended pregnancy or more.

DISCUSSION

These findings support implementing interventions to increase the uptake of effective contraception, as successfully demonstrated in the ACCORd trial, in general practice.

The management of women with ductal carcinoma in situ of the breast in Australia and New Zealand between 2007 and 2016

BACKGROUND

The incidence of detected ductal carcinoma in situ (DCIS) continues to increase and now accounts for 14% of all breast cancer, and 20%-25% of screen-detected cases. Treatment trends of DCIS are important in order to inform the ongoing debate about possible overdiagnosis and overtreatment, but have not been investigated for over a decade in Australia and New Zealand. Against this background, we aimed to describe the temporal trends in management of DCIS in Australian and New Zealander women.

METHODS

Using the BreastSurgANZ Quality Audit (BQA) database, we conducted a descriptive study of the trends of management of DCIS in Australia and New Zealand from 2007 to 2016. We assessed the frequency of surgical treatments, adjuvant therapies, and axillary surgery conducted in women with pure DCIS.

RESULTS

There were 17 883 cases of pure DCIS in 2007-2016 in Australia and New Zealand recorded in the BQA database. The treatment patterns were consistent with no changes over time. The most common surgical treatment was breast-conserving surgery (66%), followed by mastectomy (37%), and 36% of women with DCIS received sentinel node biopsy (SNB).

CONCLUSION

The clinical management of women diagnosed with DCIS in Australia and New Zealand, appears stable over time. A substantial proportion of women with DCIS receive SNB and this aspect of surgical care warrants further exploration to determine whether it represents appropriate care. These results, alongside the outcomes of the ongoing clinical trials on the management of DCIS, will help inform if any changes to best practice treatment are required.

A systematic review and meta-analysis of the prevalence of left ventricular non-compaction in adults

AIMS

To assess the reported prevalence of left ventricular non-compaction (LVNC) in different adult cohorts, taking in to consideration the role of diagnostic criteria and imaging modalities used.

METHODS AND RESULTS

A systematic review and meta-analysis of studies reporting LVNC prevalence in adults. Studies were sourced from Pre-Medline, Medline, and Embase and assessed for eligibility according to inclusion criteria. Eligible studies provided a prevalence of LVNC in adult populations (≥12 years). Studies were assessed, and data extracted by two independent reviewers. Fifty-nine eligible studies documenting LVNC in 67 unique cohorts were included. The majority of studies were assessed as moderate or high risk of bias. The pooled prevalence estimates for LVNC were consistently higher amongst cohorts diagnosed on cardiac magnetic resonance (CMR) imaging (14.79%, n = 26; I2 = 99.45%) compared with echocardiogram (1.28%, n = 36; I2 = 98.17%). This finding was unchanged when analysis was restricted to studies at low or moderate risk of bias. The prevalence of LVNC varied between disease and population representative cohorts. Athletic cohorts demonstrated high pooled prevalence estimates on echocardiogram (3.16%, n = 5; I2 = 97.37%) and CMR imaging (27.29%, n = 2).

CONCLUSION

Left ventricular non-compaction in adult populations is a poorly defined entity which likely encompasses both physiological adaptation and pathological disease. There is a higher prevalence with the introduction of newer imaging technologies, specifically CMR imaging, which identify LVNC changes more readily. The clinical significance of these findings remains unclear; however, there is significant potential for overdiagnosis, overtreatment, and unnecessary follow-up.

Informing Women About Overdetection in Breast Cancer Screening: Two-Year Outcomes From a Randomized Trial

BACKGROUND

Supporting well-informed decisions about breast cancer screening requires communicating that inconsequential disease may be detected, leading to overdiagnosis and overtreatment. Having previously shown that telling women about overdetection improved informed choice, we investigated effects on screening knowledge and participation over 2 years.

METHODS

We conducted a community-based, parallel-group, randomized controlled trial in Australia. Participants were women aged 48-50 years, without personal or strong family history of breast cancer, who had not undergone mammography in the past 2 years. We randomly assigned 879 women to receive the intervention decision aid (evidence-based information on overdetection, breast cancer mortality reduction, and false-positives) or control decision aid (identical but without overdetection information). We interviewed 838 women postintervention and recontacted them for follow-up at 6 months and 1 and 2 years. Main outcomes for this report are screening knowledge and participation.

RESULTS

We interviewed 790, 746, and 712 participants at 6 months, 1, and 2 years, respectively. The intervention group demonstrated superior knowledge throughout follow-up. After 2 years, conceptual knowledge was adequate in 123 (34.4%) of 358 women in the intervention group compared with 71 (20.1%) of 354 control participants(odds ratio = 2.04, 95% confidence interval = 1.46 to 2.85). Groups were similar in total screening participation (200 [55.1%] vs 204 [56.0%]; = 0.97, 95% confidence interval = 0.73 to 1.29).

CONCLUSIONS

A brief decision aid produced lasting improvement in women's understanding of potential consequences of screening, including overdetection, without changing participation rates. These findings support the use of decision aids for breast cancer screening.

Impact of analysis technique on our understanding of the natural history of labour: a simulation study

OBJECTIVE

To evaluate the discrepancy between historical and more recent descriptions of the first stage of labour by testing whether the statistical techniques used recently (repeated-measures polynomial and interval-censored regression) were appropriate for detection of periods of rapid acceleration of cervical dilatation as might occur at the time of transition from a latent to an active phase of labour.

DESIGN AND SETTING

A simulation study using regression techniques.

SAMPLE

We created a simulated data set for 500 000 labours with clearly defined latent and active phases using the parameters described by Friedman. Additionally, we created a data set comprising 500 000 labours with a progressively increasing rate of cervical dilatation.

METHODS

Repeated-measures polynomial regression was used to create summary labour curves based on simulated cervical examinations. Interval-censored regression was used to create centimetre-by-centimetre estimates of rates of cervical dilatation and their 95th centiles.

MAIN OUTCOME MEASURES

Labour summary curves and rates of cervical dilatation.

RESULTS

Repeated-measures polynomial regression did not detect the rapid acceleration in cervical dilatation (i.e. acceleration phase) and overestimated lengths of labour, especially at smaller cervical dilatations. There was a two-fold overestimation in the mean rate of cervical dilatation from 4 to 6 cm. Interval-censored regression overestimated median transit times, at 4- to 5-cm cervical dilatation or when cervical examinations occurred less frequently than 0.5- to 1.5-hourly.

CONCLUSION

Repeated-measures polynomial regression and interval-censored regression should not be routinely used to define labour progress because they do not accurately reflect the underlying data.

TWEETABLE ABSTRACT

Repeated-measures polynomial and interval-censored regression techniques are not appropriate to model first stage of labour.

Estimating the potential impact of interventions to reduce over-calling and under-calling of melanoma

BACKGROUND

Pathologists sometimes disagree over the histopathologic diagnosis of melanoma. 'Over-calling' and 'under-calling' of melanoma may harm individuals and healthcare systems.

OBJECTIVES

To estimate the extent of 'over-calling' and 'under-calling' of melanoma for a population undergoing one excision per person and to model the impact of potential solutions.

METHODS

In this epidemiological modelling study, we undertook simulations using published data on the prevalence and diagnostic accuracy of melanocytic histopathology in the U.S.

POPULATION

We simulated results for 10 000 patients each undergoing excision of one melanocytic lesion, interpreted by one community pathologist. We repeated the simulation using a hypothetical intervention that improves diagnostic agreement between community pathologist and a specialist dermatopathologist. We then evaluated four scenarios for how melanocytic lesions judged to be neither clearly benign (post-test probability of melanoma < 5%), nor clearly malignant (post-test probability of melanoma > 90%) might be handled, before sending for expert dermatopathologist review to decide the final diagnosis. These were (1) no intervention before expert review, (2) formal second community pathologist review, (3) intervention to increase diagnostic agreement and (4) both the intervention and formal second community pathologist review. The main outcomes were the probability of 'over-calling' and 'under-calling' melanoma, and number of lesions requiring expert referral for each scenario.

RESULTS

For 10 000 individuals undergoing excision of one melanocytic lesion, interpreted by a community pathologist, a hypothetical intervention to improve histopathology agreement reduced the number of benign lesions 'over-called' as melanoma from 308 to 164 and the number of melanomas 'under-called' from 289 to 240. If all uncertain diagnoses were sent for expert review, the number of referrals would decrease from 1500 to 737 cases if formal second community pathologist review was used, and to 701 cases if the hypothetical intervention was additionally used.

CONCLUSIONS

Interventions to improve histopathology agreement may reduce melanoma 'over-calling' and 'under-calling'.

Overdiagnosis of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: A Systematic Scoping Review

IMPORTANCE

Reported increases in attention-deficit/hyperactivity disorder (ADHD) diagnoses are accompanied by growing debate about the underlying factors. Although overdiagnosis is often suggested, no comprehensive evaluation of evidence for or against overdiagnosis has ever been undertaken and is urgently needed to enable evidence-based, patient-centered diagnosis and treatment of ADHD in contemporary health services.

OBJECTIVE

To systematically identify, appraise, and synthesize the evidence on overdiagnosis of ADHD in children and adolescents using a published 5-question framework for detecting overdiagnosis in noncancer conditions.

EVIDENCE REVIEW

This systematic scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews and Joanna Briggs Methodology, including the PRISMA-ScR Checklist. MEDLINE, Embase, PsychINFO, and the Cochrane Library databases were searched for studies published in English between January 1, 1979, and August 21, 2020. Studies of children and adolescents (aged ≤18 years) with ADHD that focused on overdiagnosis plus studies that could be mapped to 1 or more framework question were included. Two researchers independently reviewed all abstracts and full-text articles, and all included studies were assessed for quality.

FINDINGS

Of the 12 267 potentially relevant studies retrieved, 334 (2.7%) were included. Of the 334 studies, 61 (18.3%) were secondary and 273 (81.7%) were primary research articles. Substantial evidence of a reservoir of ADHD was found in 104 studies, providing a potential for diagnoses to increase (question 1). Evidence that actual ADHD diagnosis had increased was found in 45 studies (question 2). Twenty-five studies showed that these additional cases may be on the milder end of the ADHD spectrum (question 3), and 83 studies showed that pharmacological treatment of ADHD was increasing (question 4). A total of 151 studies reported on outcomes of diagnosis and pharmacological treatment (question 5). However, only 5 studies evaluated the critical issue of benefits and harms among the additional, milder cases. These studies supported a hypothesis of diminishing returns in which the harms may outweigh the benefits for youths with milder symptoms.

CONCLUSIONS AND RELEVANCE

This review found evidence of ADHD overdiagnosis and overtreatment in children and adolescents. Evidence gaps remain and future research is needed, in particular research on the long-term benefits and harms of diagnosing and treating ADHD in youths with milder symptoms; therefore, practitioners should be mindful of these knowledge gaps, especially when identifying these individuals and to ensure safe and equitable practice and policy.

Women's satisfaction with and ongoing use of hormonal long-acting methods compared to the oral contraceptive pill: Findings from an Australian general practice cluster randomised trial (ACCORd)

BACKGROUND

The Australian Contraceptive ChOice pRoject (ACCORd) aimed to assess the impact of a complex general practice intervention on the uptake of long-acting reversible contraceptives (LARC).

AIMS

Using survey data from enrolled women, we aimed to compare the ongoing use and satisfaction of women who chose one of the hormonal LARC methods including the levonorgestrel intrauterine system (LNG-IUS) or levonorgestrel implant compared to the oral contraceptive pill (OCP).

MATERIALS AND METHODS

We used the data from participants' baseline, six and 12-month surveys to identify new users of implants, LNG-IUS or OCP. We included demographic information, ongoing use of the contraceptive method, reasons for dissatisfaction and discontinuation and experience of side-effects. Proportions were compared using χ² tests.

RESULTS

Of the 740 women enrolled in ACCORd, 176 started using a hormonal LARC or OCP in the study's first six months with 76 using the IUS (43%), 60 the implant (34%) and 40 (23%) the OCP. Twelve-month continuation rates for the LNG-IUS, implant and OCP were 93, 83 and 65% respectively (P < 0.001). Satisfaction was highest among the LNG-IUS users; 86% were very/somewhat satisfied compared to 75% of implant users and 61% of OCP users (P < 0.001). Main reasons for method dissatisfaction were irregular bleeding and mood changes which were similar for all methods.

CONCLUSIONS

This study provides further evidence that hormonal LARC methods have higher continuation and satisfaction rates compared to the OCP with similar side-effects. Since hormonal LARC methods have the highest contraceptive efficacy, these should be offered first-line to women.

The potential for overdiagnosis and underdiagnosis because of blood pressure variability: a comparison of the 2017 ACC/AHA, 2018 ESC/ESH and 2019 NICE hypertension guidelines

OBJECTIVE

To estimate the extent that BP measurement variability may drive over- and underdiagnosis of 'hypertension' when measurements are made according to current guidelines.

METHODS

Using data from the National Health and Nutrition Examination Survey and empirical estimates of within-person variability, we simulated annual SBP measurement sets for 1 000 000 patients over 5 years. For each measurement set, we used an average of multiple readings, as recommended by guidelines.

RESULTS

The mean true SBP for the simulated population was 118.8 mmHg with a standard deviation of 17.5 mmHg. The proportion overdiagnosed with 'hypertension' after five sets of office or nonoffice measurements using the 2017 American College of Cardiology guideline was 3-5% for people with a true SBP less than 120 mmHg, and 65-72% for people with a true SBP 120-130 mmHg. These proportions were less than 1% and 14-33% using the 2018 European Society of Hypertension and 2019 National Institute for Health and Care Excellence guidelines (true SBP <120 and 120-130 mmHg, respectively). The proportion underdiagnosed with 'hypertension' was less than 3% for people with true SBP at least 140 mmHg after one set of office or nonoffice measurements using the 2017 American College of Cardiology guideline, and less than 18% using the other two guidelines.

CONCLUSION

More people are at risk of overdiagnosis under the 2017 American College of Cardiology guideline than the other two guidelines, even if nonoffice measurements are used. Making clinical decisions about cardiovascular prediction based primarily on absolute risk, minimizes the impact of blood pressure variability on overdiagnosis.

Persistent occiput posterior position outcomes following manual rotation: a randomized controlled trial

BACKGROUND

Persistent occiput posterior position in labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation from the occiput posterior position to the occiput anterior position in the second stage of labor is considered a safe and easy to perform procedure that in observational studies has shown promise as a method for preventing operative deliveries.

OBJECTIVE

This study aimed to determine the efficacy of prophylactic manual rotation in the management of occiput posterior position for preventing operative delivery. The hypothesis was that among women who are at least 37 weeks pregnant and whose baby is in the occiput posterior position early in the second stage of labor, manual rotation will reduce the rate of operative delivery compared with the "sham" rotation.

STUDY DESIGN

A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 4 tertiary hospitals was conducted in Australia. A total of 254 nulliparous and parous women with a term pregnancy and a baby in the occiput posterior position in the second stage of labor were randomly assigned to receive either a prophylactic manual rotation (n=127) or a sham rotation (n=127). The primary outcome was operative delivery (cesarean, forceps, or vacuum delivery). Secondary outcomes were cesarean delivery, combined maternal mortality and serious morbidity, and combined perinatal mortality and serious morbidity. Analysis was by intention to treat. Proportions were compared using chi-square tests adjusted for stratification variables using the Mantel-Haenszel method or the Fisher exact test. Planned subgroup analyses by operator experience and by manual rotation technique (digital or whole-hand rotation) were performed.

RESULTS

Operative delivery occurred in 79 of 127 women (62%) assigned to prophylactic manual rotation and 90 of 127 women (71%) assigned to sham rotation (common risk difference, 12; 95% confidence interval, -1.7 to 26; P=.09). Among more experienced operators or investigators, operative delivery occurred in 46 of 74 women (62%) assigned to manual rotation and 52 of 71 women (73%) assigned to a sham rotation (common risk difference, 18; 95% confidence interval, -0.5 to 36; P=.07). Cesarean delivery occurred in 22 of 127 women (17%) in both groups. Instrumental delivery (forceps or vacuum) occurred in 57 of 127 women (45%) assigned to prophylactic manual rotation and 68 of 127 women (54%) assigned to sham rotation (common risk difference, 10; 95% confidence interval, -3.1 to 22; P=.14). There was no significant difference in the combined maternal and perinatal outcomes.

CONCLUSION

Prophylactic manual rotation did not result in a reduction in the rate of operative delivery. Given manual rotation was associated with a nonsignificant reduction in operative delivery, more randomized trials are needed, as our trial might have been underpowered. In addition, further research is required to further explore the potential impact of operator or investigator experience.

Unwanted Sex Due to Intoxication among Australians Aged 16-69 Years

Intoxication can be a factor in unwanted sex, but research on the extent of the issue in both women and men is limited. We assessed the prevalence, correlates, and 10-year time-trends of unwanted sex due to intoxication among a representative sample of 4,279 women and 3,875 men aged 16-69 years in Australia and considered how these vary by gender. In 2012-13, 16% of women and 10% of men reported ever having had a sexual experience when they "did not want to because they were too drunk or high at the time." For both women and men, this was associated with younger age, bisexual activity, and reports of lifetime injection drug use, sexually transmitted infections, and forced sex. Among women only, it was associated with drinking above guideline levels and ever having terminated a pregnancy. Among men only, it was associated with current tobacco smoking, elevated psychosocial distress, and poor general health. Compared with 2001-02 data, fewer men reported unwanted intoxicated sex, while there were no changes for women as a whole. Interpreting these findings through an intersectional assemblage framework supports stronger understanding of the multiple factors influencing sexuality and substance use with implications for promoting equity, safety, and sexual health.

Increasing the uptake of long-acting reversible contraception in general practice: the Australian Contraceptive ChOice pRoject (ACCORd) cluster randomised controlled trial longitudinal follow-up protocol

INTRODUCTION

Through addressing main barriers to the uptake of long-acting reversible contraceptives (LARCs) among Australian women, the Australian Contraceptive ChOice pRoject (ACCORd) trialled an educational intervention targeting general practitioners (GPs) and provided those in the intervention group with a rapid referral service for quick insertion. The cluster randomised controlled trial resulted in greater uptake of LARC in the intervention group. This protocol paper describes a longitudinal follow-up to the ACCORd Study to assess the long-term efficacy and cost-effectiveness of the intervention.

METHODS AND ANALYSIS

Women participants (patients of ACCORd GPs) completed a baseline, 6-month and 12-month survey. These participants will be invited to complete an additional follow-up survey 3 years post completion of their baseline interview. Based on the original ACCORd Study tools, the online survey will address long-term outcomes including contraceptive continuation rates and reproductive history, any unintended pregnancies, satisfaction and concerns with their current contraceptive method, and an assessment of quality of life. We will analyse data using binary regression models with generalised estimating equations and robust standard errors to account for clustering.

DISCUSSION

Demonstration of sustained use, effectiveness at reducing unwanted pregnancies and cost-effectiveness of this strategy among this cohort of Australian primary care patients, will strengthen the policy and programme urgency of addressing wider dissemination of these strategies and replicating the study elsewhere.

ETHICS AND DISSEMINATION

The ACCORd Study received approval from the Monash University Human Research Ethics Committee: CF16/188-201000080. Additionally, an amendment to conduct this 3-year longitudinal follow-up survey has been approved. The trial follow-up outcomes will be disseminated through formal academic pathways, including journal articles, national and international conferences and reports as well as using more 'mainstream' strategies such as seminars, workshops and media engagement. Additionally, outcomes will be communicated through policy briefs to Australian state and federal governments.

TRAIL REGISTRATION NUMBER

This trial is registered with the Australian and New Zealand Trials Registry ACTRN12615001346561. Recruitment and data collection have been completed for the baseline, 6-month and 12-month surveys. Data collection for the 3-year survey commenced in August 2019.

Contraception provision in the postpartum period: Knowledge, views and practices of midwives

BACKGROUND

Women are susceptible to unintended pregnancies in the first year after giving birth, particularly as consideration of contraception may be a low priority during this time. Discussing and providing contraception before women leave hospital after giving birth may prevent rapid repeat pregnancy and its associated risks. Midwives are well placed to assist with contraceptive decision-making and provision; however, this is not routinely undertaken by midwives in the Australian hospital setting and little is known regarding their views and experiences in relation to contraception.

METHODS

An anonymous survey was conducted with midwives at two urban hospitals in New South Wales to better understand their contraceptive knowledge, views and practices regarding midwifery-led contraception provision in the postpartum period.

FINDINGS

The survey was completed by 128 midwives. Most agreed that information about contraception provided in the postpartum period is valuable to women, although their knowledge about different methods was variable. The majority (88%) believed that midwives have a role in providing contraceptive information, and 79% reported currently providing contraceptive counselling. However, only 14% had received formal training in this area.

CONCLUSION

Findings demonstrate that most midwives provide some contraception information and believe this is an important part of a midwife's role. Yet most have not undertaken formal training in contraception. Additional research is needed to explore the content and quality of midwives' contraception discussions with women. Training midwives in contraceptive counselling would ensure women receive accurate information about available options. Upskilling midwives in contraception provision may increase postpartum uptake and reduce rapid repeat pregnancies.

Effectiveness of a peer education gender and health project for men in Timor-Leste

ISSUE ADDRESSED

In response to high rates of gender-based violence and poor sexual and reproductive health indicators in Timor-Leste, a 'Men's Health Project' was implemented in two rural communities in 2013. A peer education model was utilised to engage men in issues regarding health, relationships and well-being.

METHODS

Community-based baseline and endline surveys were undertaken to evaluate the project in the two communities.

RESULTS

In 2013, 401 men and boys completed a baseline survey, and 400 completed an endline survey in 2016. Significant differences were found in a number of areas, with more men in the endline survey aware of the negative impacts of alcohol, safe pregnancy practices, family planning and sexually transmitted infections. Many men reported making the major decisions in their family in both surveys.

CONCLUSIONS

The peer education approach engaged men in health awareness and contributed to increasing knowledge of sexual and reproductive health and other health issues. However, while education and positive attitudes are an important foundation for change, other enabling mechanisms including vital infrastructure, services and health personnel must be in place to facilitate change and increase access to information and healthcare. Findings highlight the importance of engaging both women and men in processes of challenging behaviours and structures that reinforce gender inequalities. SO WHAT?: Peer education appears to be an effective model for engaging community members in gender and health issues in Timor-Leste. The Men's Health Project enabled men to participate in health awareness and issues regarding health, relationships and well-being.

Quality of life among caregivers of people with end-stage kidney disease managed with dialysis or comprehensive conservative care

Background

To measure health-related and care-related quality of life among informal caregivers of older people with end-stage kidney disease (ESKD), and to determine the association between caregiver quality of life and care recipient’s treatment type.

Methods

A prospective cross-sectional study was conducted. Three renal units in the UK and Australia were included. Informal caregivers of people aged ≥75 years with ESKD managed with dialysis or comprehensive conservative non-dialytic care (estimated glomerular filtration (eGFR) ≤10 mL/min/1.73m²) participated. Health-related quality of life (HRQoL) was assessed using Short-Form six dimensions (SF-6D, 0–1 scale) and care-related quality of life was assessed using the Carer Experience Scale (CES, 0–100 scale). Linear regression assessed associations between care-recipient treatment type, caregiver characteristics and the SF-6D utility index and CES scores.

Results

Of 63 caregivers, 49 (78%) were from Australia, 26 (41%) cared for an older person managed with dialysis, and 37 (59%) cared for an older person managed with comprehensive conservative care. Overall, 73% were females, and the median age of the entire cohort was 76 years [IQR 68–81]. When adjusted for caregiver sociodemographic characteristics, caregivers reported significantly worse carer experience (CES score 15.73, 95% CI 5.78 to 25.68) for those managing an older person on dialysis compared with conservative care. However, no significant difference observed for carer HRQoL (SF-6D utility index − 0.08, 95% CI − 0.18 to 0.01) for those managing an older person on dialysis compared with conservative care.

Conclusions

Our data suggest informal caregivers of older people on dialysis have significantly worse care-related quality of life (and therefore greater need for support) than those managed with comprehensive conservative care. It is important to consider the impact on caregivers’ quality of life when considering treatment choices for their care recipients.