Acceptability and optimisation of resources to support antidepressant cessation: a qualitative think-aloud study with patients in Australian primary care

BACKGROUND

Stopping long-term (>12 months) antidepressant use can be difficult due to unpleasant withdrawal symptoms. Many people do not recognise withdrawal symptoms or understand how to minimise them while safely discontinuing antidepressants. To address the gaps, the authors developed the 'Redressing long-term antidepressant use' (RELEASE) resources, comprising a medicines information brochure, a decision aid, and drug- specific hyperbolic tapering protocols.

AIM

To explore patients' acceptability of the RELEASE resources to optimise their use and impact.

DESIGN AND SETTING

A think-aloud interview study among adults with lived experience of long-term antidepressant use conducted in south-east Queensland, Australia, between November 2021 and June 2022.

METHOD

Participants were purposively sampled from general practices and interviewed face-to-face or via videoconferencing. Participants verbalised their thoughts, impressions, and feelings while engaging with each resource. Interviews were analysed using a deductive coding framework, including codes related to acceptability and optimisation. Interviews were analysed in a series of four tranches, with iterative modifications made to resources after each tranche.

RESULTS

Participants (n = 14) reported the resources to be relevant, informative, motivational, and usable. Participants' comments informed modifications, including changes to wording, content order, and layout. Several participants expressed frustration that they had not had these resources earlier, with one reporting the information could have been 'life changing'. Many commented on the need for these resources to be widely available to both patients and doctors.

CONCLUSION

The RELEASE resources were found to be acceptable, useful, and potentially life changing. The effectiveness of these consumer-informed resources in supporting safe cessation of long-term antidepressants is currently being tested in general practice.

Lessons from the Netherlands for Australia: cross-country comparison of trends in antidepressant dispensing 2013-2021 and contextual factors influencing prescribing

BACKGROUND

There is concern internationally about increasing antidepressant use. Most antidepressants are prescribed in general practice. The aim of this study was to compare trends in antidepressant dispensing in Australia and the Netherlands over the 9years from 2013 to 2021, and to explore reasons for differences.

METHODS

A convergent mixed methods study including analysis of publicly available antidepressant dispensing data obtained from Australia's Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme and the Dutch Foundation for Pharmaceutical Statistics and a search of relevant literature to compare contextual factors influencing prescribing were undertaken.

RESULTS

In 2013, antidepressant dispensing rates in Australia were nearly twice as high as those in the Netherlands (82.5 versus 44.3DDD/1000/day) and increased to be more than twice as high by 2021 (115.6 versus 48.8DDD/1000/day). Antidepressant dispensing increased by 40% in Australia over the nine study years, but by only 10% in the Netherlands. Our scan of the literature confirms that while population factors, health system structure, and clinical guideline recommendations are largely consistent across the two countries, a multifaceted approach in the Netherlands involving improved access to non-pharmacological alternatives, initiatives targeting safer antidepressant prescribing, and tight regulation of pharmaceutical industry influence on prescribers, has successfully curtailed increasing antidepressant use.

CONCLUSIONS

Australia may learn from the Netherlands' approach to redress increasing antidepressant use.

Supporting complex care in general practice via an eConsultant model of care: the Australian specialist perspective

BACKGROUND

Accessing timely specialist physician advice and guidance is of critical importance to both Australian GP specialists (GPs) and their patients. The traditional method of referral, triage and subsequent face-to-face (FTF) consultation is facing challenges from an ever increasing volume of referrals and the needs of underserved populations. In response to such issues, electronic consults (eConsults) have been successfully used internationally to provide GPs with a means of asynchronously accessing specialist physician advice and guidance within 72h. Few studies have addressed the potential impact of eConsults from the view of the non-GP specialist receiving the request, and none specifically related to specialist adult medicine physicians. The aim of this study was to determine the perceptions of current Royal Australasian College of Physicians (RACP) adult medicine Fellows towards establishing an eConsult model of care within their own clinical practice.

METHODS

Semi-structured interviews were conducted with 14 RACP adult medicine Fellows between December 2019 and February 2020. Purposive and snowball sampling strategies were used to recruit physicians of differing ages and gender from diverse specialties and healthcare settings. The data were subjected to a descriptive thematic analysis.

RESULTS

We describe five key themes of relevance to study participants: (1) improved access to non-GP specialist care; (2) the business model in relation to remuneration and time; (3) enhanced GP-Physician relationships; (4) impact on physician work-life balance; and (5) the need for a structured model of care. There was broad consensus that a significant number of outpatient referrals to adult medicine physicians would be more appropriately addressed in primary care with support via an asynchronous eConsult arrangement. RACP Fellows agreed this could improve access to timely specialist advice, place downward pressure on outpatient FTF clinic waiting times and reduce unnecessary patient travel.

CONCLUSION

These findings identify the drivers and barriers to the establishment of an Australian eConsultant model of care from the adult medicine physician's perspective.

RELEASE (REdressing Long-tErm Antidepressant uSE): protocol for a 3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1 in general practice

BACKGROUND

Many people experience withdrawal symptoms when they attempt to stop antidepressants. Withdrawal symptoms are readily misconstrued for relapse or ongoing need for medication, contributing to long-term use (> 12 months). Long-term antidepressant use is increasing internationally yet is not recommended for most people. Long-term use is associated with adverse effects including weight gain, sexual dysfunction, lethargy, emotional numbing and increased risk of falls and fractures. This study aims to determine the effectiveness of two multi-strategy interventions (RELEASE and RELEASE+) in supporting the safe cessation of long-term antidepressants, estimate cost-effectiveness, and evaluate implementation strategies.

METHODS

DESIGN: 3-arm pragmatic cluster randomised controlled trial effectiveness-implementation hybrid type-1.

SETTING

primary care general practices in southeast Queensland, Australia.

POPULATION

adults 18 years or older taking antidepressants for longer than 1 year. Practices will be randomised on a 1.5:1:1 ratio of Usual care:RELEASE:RELEASE+.

INTERVENTION

RELEASE for patients includes evidence-based information and resources and an invitation to medication review; RELEASE for GPs includes education, training and printable resources via practice management software. RELEASE+ includes additional internet support for patients and prescribing support including audit and feedback for GPs.

OUTCOME MEASURES

the primary outcome is antidepressant use at 12 months self-reported by patients. Cessation is defined as 0 mg antidepressant maintained for at least 2 weeks.

SECONDARY OUTCOMES

at 6 and 12 months are health-related quality of life, antidepressant side effects, well-being, withdrawal symptoms, emotional numbing, beliefs about antidepressants, depressive symptoms, and anxiety symptoms; and at 12 months 75% reduction in antidepressant dose; aggregated practice level antidepressant prescribing, and health service utilisation for costs.

SAMPLE SIZE

653 patients from 28 practices. A concurrent evaluation of implementation will be through mixed methods including interviews with up to 40 patients and primary care general practitioners, brief e-surveys, and study administrative data to assess implementation outcomes (adoption and fidelity).

DISCUSSION

The RELEASE study will develop new knowledge applicable internationally on the effectiveness, cost-effectiveness, and implementation of two multi-strategy interventions in supporting the safe cessation of long-term antidepressants to improve primary health care and outcomes for patients.

TRIAL REGISTRATION

ANZCTR, ACTRN12622001379707p. Registered on 27 October 2022.

An eConsultant versus a hospital-based outpatient consultation for general (internal) medicine: a costing analysis

BACKGROUND

The eConsultant model of care is an outpatient substitution approach which has been evaluated and implemented extensively internationally. It provides an asynchronous, digital, clinician-to-clinician advice service, giving primary care physicians remote access to specialist support for patient care within 3 business days. Results from initial trials of the eConsultant model in Australia support international evidence of reduced wait times and improved access to specialist input, avoidance of face-to-face hospital outpatient visits, and better integrated care. This study compared the cost of delivery of an eConsultant episode of care with that of a hospital-based outpatient appointment.

METHODS

A cost-minimisation analysis, using a decision analytic model, was used to compare the two approaches. eConsultant costs were calculated from specialist reported data (minutes spent preparing the response; the number of patients referred subsequently for a hospital-based outpatient appointment) and administration staff data (time spent recording the occasion-of-service). Outpatient costs were calculated using finance data and information from outpatient clinic managers at the hospital-based outpatient clinic. The primary outcome was incremental cost saving per patient from a hospital system perspective. Uncertainty was explored using one-way sensitivity analyses and characterised with probabilistic sensitivity analysis using 10,000 Monte Carlo simulations.

RESULTS

The traditional referral pathway cost estimate was $587.20/consult compared to $226.13/consult for an eConsultant episode: an efficiency saving of $361.07 per patient. The incremental difference between eConsultant and traditional care was most sensitive to the cost estimate of an outpatient attendance, the time for a specialist to complete an eConsult, and the probability of a patient requiring a face-to-face hospital-based attendance following an eConsult. However, at the upper bounds of each of these estimates, an eConsult remained the most cost-efficient model. In 96.5% of the Monte Carlo simulations eConsult was found to be more cost efficient than the traditional approach.

CONCLUSIONS

The eConsultant model of care was associated with a 61.5% efficiency gain, allowing diversion of support to hospital-based outpatient appointments.

Implementing a general practitioner-to-general physician eConsult service (eConsultant) in Australia

Background

In response to lengthy wait times for specialist outpatient appointments, electronic consultation (eConsult) services have developed globally, providing asynchronous, secure and timely communication between general practitioner (GP) and specialist. This study aims to track adoption of a Queensland eConsultant service in two Australian Primary Health Networks (Western Queensland and Brisbane South) to understand key barriers and enablers to adoption and inform modification of the implementation strategy. 

Methods

Our theory-informed mixed-methods evaluation assessed implementation between July 2020 and March 2022. Adoption and implementation activities were prospectively recorded in bespoke tracking spreadsheets with implementation activities coded against the Expert Recommendations for Implementing Change (ERIC) strategies. Semi-structured interviews with GPs and stakeholders informed by the Consolidated Framework for Implementation Research (CFIR) were conducted to understand determinants of implementation. 

Results

Of the 40 practices invited to take part in the eConsultant service, 20 (50%) enrolled. Of the 97 GPs who consented, 38 sent at least one Request for Advice (RFA) to the eConsultant with a total of 112 RFA sent. Implementation was predominantly guided by eight strategies. Qualitative interviews were conducted with 11 GPs and 4 stakeholders (12 from rural/remote regions, 11 females and two sole practitioners). Interviewees felt the eConsultant service supported outpatient appointment avoidance and provided efficient, timely access to specialist support for GPs and their patients. Barriers identified to using eConsultant related to digital infrastructure, competing priorities, and keeping the service ‘front of mind’. Key enablers identified were the relative advantage of eConsultant over other options, patient benefits and COVD-19 facilitating the use of digital technology.

Conclusions

This evaluation highlighted service enablers as well as user priorities for broader implementation. A focus on a well-integrated digital system and availability of a variety of eConsultant specialties are seen as key strategies to embedding the eConsultant option in GP advice processes in Australia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08663-2.

Feasibility of an asynchronous general practitioner-to-general physician eConsultant outpatient substitution program: A Queensland pilot study

BACKGROUND AND OBJECTIVES

The use of an 'eConsultant' to support the family physician is an established outpatient substitution model in North America. This pilot study investigates the feasibility of the eConsultant model for complex chronic disease management within the Australian setting.

METHOD

This pilot study was implemented in one urban and four rural/remote general practices in one state. The general practitioner (GP) sent a request for advice (RFA), a clinical summary with a specific clinical question/s, via secure messaging to a physician working remotely. Responses were required for GP/patient follow-up within 72 hours.

RESULTS

The mean (standard deviation [SD]) time for general physician reply was 2.1 (1.2) days, and mean (SD) time from initial to subsequent GP/patient review was 14.8 (16.7) days. Only 13.3% of eConsultations required a subsequent face-to-face outpatient department appointment.

DISCUSSION

The eConsultant model is feasible in Australia, with potential for improving access and reducing time to non-GP specialist input.

Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults

BACKGROUND

Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants.

OBJECTIVES

To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults.

SEARCH METHODS

We searched all databases for randomised controlled trials (RCTs) until January 2020.

SELECTION CRITERIA

We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety.

AUTHORS' CONCLUSIONS

Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression.   There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.

Community-based integrated care versus hospital outpatient care for managing patients with complex type 2 diabetes: costing analysis

Objective This study compared the cost of an integrated primary-secondary care general practitioner (GP)-based Beacon model with usual care at hospital outpatient departments (OPDs) for patients with complex type 2 diabetes. Methods A costing analysis was completed alongside a non-inferiority randomised control trial. Costs were calculated using information from accounting data and interviews with clinic managers. Two OPDs and three GP-based Beacon practices participated. In the Beacon practices, GPs with a special interest in advanced diabetes care worked with an endocrinologist and diabetes nurse educator to care for referred patients. The main outcome was incremental cost saving per patient course of treatment from a health system perspective. Uncertainty was characterised with probabilistic sensitivity analysis using Monte Carlo simulation. Results The Beacon model is cost saving: the incremental cost saving per patient was A$365 (95% confidence interval -A$901, A$55) and was cost saving in 93.7% of simulations. The key contributors to the variance in the cost saving per patient course of treatment were the mean number of patients seen per site and the number of additional presentations per course of treatment associated with the Beacon model. Conclusions Beacon clinics were less costly per patient course of treatment than usual care in hospital OPDs for equivalent clinical outcomes. Local contractual arrangements and potential variation in the operational cost structure are of significant consideration in determining the cost-efficiency of Beacon models. What is known about this topic? Despite the growing importance of achieving care quality within constrained budgets, there are few costing studies comparing clinically-equivalent hospital and community-based care models. What does this paper add? Costing analyses comparing hospital-based to GP-based health services require considerable effort and are complex. We show that GP-based Beacon clinics for patients with complex chronic disease can be less costly per patient course of treatment than usual care offered in hospital OPDs. What are the implications for practitioners? In addition to improving access and convenience for patients, transferring care from hospital to the community can reduce health system costs.

The impact of badminton lessons on health and wellness of young adults with intellectual disabilities: a pilot study

Background: Physical activity has been proposed as a context to foster the healthy development of individuals and reduce the risk of many chronic problems. This study evaluates the impact of badminton lessons on health and wellness in young adults with intellectual disabilities (ID). Methods: Eighteen participants with ID (14 males and 4 females, aged 19-26) and with little or no experience in badminton were assigned to an exercise group and a control group. The curriculum selected was Shuttle Time Starter Lessons. The exercise group practiced for 50 min each session, twice a week for 10 lessons with peers, while the control group maintained a regular life schedule. Physiological measures, motor performance, Special Olympics Individual Badminton Skills Assessment; and psychological measures were conducted before and after the program. A Wilcoxon signed-rank test was conducted to compare pre- and post-tests in each group. Results: The significantly reduced resting heart rate, longer walking distances in the 6-minute walk test, and better performance in badminton skills were evident in the exercise group. Further, a significantly increased left frontal alpha asymmetry was seen in the exercise group with participants expressing positive effects after the inclusive badminton program. Finally, resting EEG frontal asymmetry seemed to be reflective of emotion in persons with ID. Conclusions: Shuttle Time Badminton Lessons could be feasible for adults with ID. School teachers and coaches may adapt it to improve health and wellness and acquire badminton skills in adults with ID. In addition, the inclusive environment can motivate their participation.

Improving quality in general practice using the Primary Care Practice Improvement Tool (PC-PIT) with Primary Health Network support

Optimal primary care sector performance is vital for ensuring the delivery of quality health services and effective clinical management of populations. The Primary Care Practice Improvement Tool (PC-PIT) incorporates subjective staff input and objective indicators to measure 13 elements of organisational performance. This study aimed to measure change in organisational performance for general practices using the PC-PIT with Primary Health Network (PHN) support. A pre-post design was used for changes in PC-PIT subjective and objective scores. Practices used results with PHN support to complete two Plan Do Study Act initiatives and were reassessed 9-months later. PC-PIT scales were dichotomised into lower and higher scores, with odds ratios used to determine effect size. Staff survey response rates were 55.4% at baseline and 50.1% at follow up. There were modest increases in the likelihood of staff rating several elements higher at follow up. When implemented with PHN support staff, the PC-PIT has the potential for effective, focussed and sustained quality improvement, with capacity to support Health Care Home model transition and implementation.

Development of Reference Materials for Paralytic Shellfish Poisoning Toxins

A project was undertaken to develop mussel reference materials that were certified for their mass fractions of saxitoxin and decarbamoyl-saxitoxin. Fifteen laboratories from various European countries participated. Three of these had major responsibility for substantial parts of the work and overall coordination of the project. The project involved 4 main activities: (1) procurement and characterization of calibrants; (2) improvement of analytical methodology; (3) preparation of reference materials, including homogeneity and stability studies; (4) 2 interlaboratory studies and a certification exercise. The joint activities resulted in 3 homogeneous and stable reference materials: 2 lyophilized mussel materials with and without naturally incurred paralytic shellfish poisoning (PSP) toxins, and a saxitoxin enrichment solution. The reference materials were certified with respect to their saxitoxin and decarbamoyl-saxitoxin content. The lyophilized mussel material with PSP toxins (CRM 542) contained <0.07 mg saxitoxin·2HCl/kg and 1.59 ± 0.20 mg decarbamoyl-saxitoxin·2HCl/kg. The lyophilized mussel material without PSP toxins (CRM 543) contained <0.07 mg saxitoxin·2HCl/kg and <0.04 mg decarbamoyl-saxitoxin·2HCl/kg. The certified value of the saxitoxin mass fraction in the saxitoxin enrichment solution (CRM 663) was 9.8 ± 1.2 μg/g.

Establishing a new model of integrated primary and secondary care based around general practice: a case study of lessons learned and challenges

This case study describes the development and implementation of an innovative integrated primary-secondary model of care for people with complex diabetes. The aim of the paper is to present the experiences of clinicians and researchers involved in implementing the 'Beacon' model by providing a discussion of the contextual factors, including lessons learned, challenges and solutions. Beacon-type models of community care for people with chronic disease are well placed to deliver on Australia's health care reform agenda, and this commentary provides rich contextual information relevant to the translation of such models into policy and practice.

Clinical outcomes of an integrated primary-secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial

AIMS/HYPOTHESIS

The aim of the study was to determine if a Beacon model of integrated care utilising general practitioners (GPs) with special interests could achieve similar clinical outcomes to a hospital-based specialist diabetes outpatient clinic.

METHODS

This pragmatic non-inferiority multisite randomised controlled trial assigned individuals with complex type 2 diabetes to care delivered by a Beacon clinic or to usual care delivered by a hospital outpatient department, in a 3:1 ratio. Owing to the nature of the study, researchers were only blinded during the allocation process. Eligible participants were aged 18 or over, had been referred by their usual GP to the hospital central referral hub with type 2 diabetes and had been triaged to be seen within 30 or 90 days. The intervention consisted of diabetes management in primary care by GPs with a special interest who had been upskilled in complex diabetes under the supervision of an endocrinologist. The primary outcome was HbA_1c at 12 months post-recruitment. The non-inferiority margin was 4.4 mmol/mol (0.4%). Both per-protocol and intention-to-treat analyses are reported.

RESULTS

Between 27 November 2012 and 14 July 2015, 352 individuals were recruited and 305 comprised the intention-to-treat sample (71 in usual care group and 234 in the Beacon model group). The Beacon model was non-inferior to usual care for both the per-protocol (difference -0.38 mmol/mol [95% CI -4.72, 3.96]; -0.03% [95% CI -0.43, 0.36]) and the intention-to-treat (difference -1.28 mmol/mol [95% CI -5.96, 3.40]; -0.12% [95% CI -0.55, 0.31]) analyses. Non-inferiority was sustained in a sensitivity analysis at 12 months. There were no statistically or clinically significant differences in the secondary outcomes of BP, lipids or quality of life as measured by the 12 item short-form health survey (SF-12v2) and the diabetes-related quality of life (DQoL-Brief) survey. Safety indicators did not differ between groups. Participant satisfaction on the eight-item client satisfaction questionnaire (CSQ-8) was good in both groups, but scores were significantly higher in the Beacon model group than the usual care group (mean [SD] 28.4 [4.9] vs 25.6 [4.9], respectively, p < 0.001).

CONCLUSIONS/INTERPRETATION

In individuals with type 2 diabetes, a model of integrated care delivered in the community by GPs with a special interest can safely achieve clinical outcomes that are not inferior to those achieved with gold-standard hospital-based specialist outpatient clinics. Individuals receiving care in the community had greater satisfaction. Further studies will determine the cost of delivering this model of care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000380897 FUNDING: The study was funded by the Australian National Health and Medical Research Council (GNT1001157).

Impact of a general practitioner-led integrated model of care on the cost of potentially preventable diabetes-related hospitalisations

AIM

To estimate potential savings for Australia's health care system through the implementation of an innovative Beacon model of care for patients with complex diabetes.

METHODS

A prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. We extracted patient hospitalisation data from the Queensland Hospital Admitted Patient Data Collection and used Australian Refined Diagnosis Related Groups to assign costs to potentially preventable hospitalisations for diabetes.

RESULTS

327 patients with complex diabetes referred by their general practitioner for specialist outpatient care were included in the analysis. The integrated model of care had potential for national cost savings of $132.5 million per year.

CONCLUSIONS

The differences in hospitalisations attributable to better integrated primary/secondary care can yield large cost savings. Models such as the Beacon are highly relevant to current national health care reform initiatives to improve the continuity and efficiency of care for those with complex chronic disease in primary care.

A qualitative follow-up study of diabetes patients' appraisal of an integrated diabetes service in primary care

As the prevalence of type 2 diabetes continues to escalate, health system reform is seeking better patient outcomes through new models of care that aim to provide the most appropriate care when needed. Patients' experiences of service innovations can shed light on the successes and challenges of implementing change. This paper explores patients' views of a new model of integrated care for patients with type 2 diabetes. A mixed-methods, randomised control trial evaluated a beacon clinic model of care for complex type 2 diabetes led by specialist general practitioners (GPs) in primary care settings in Brisbane, Australia. In this qualitative sub-study conducted between May 2014 and January 2015, 25 consenting participants were re-interviewed after 12 months using semi-structured questions, to explore their experiences of the new model of care. Interview transcripts were analysed thematically. In the first theme, Organised for patient-centred care, patients appraised the structural elements of the clinic. For most, it was an enabling experience which included convenience, flexibility and prompt communication back to the referring GPs. The preferences of a minority were partly realised, as they tried to understand the clinical purpose in comparison with traditional care. The second theme, Positioned as partners in care, revealed the pivotal role of patient-clinician relationships in patients' engagement with advice and self-care. Most found clinicians' collaborative approach engaging and motivating. A small minority with contextual concerns were disappointed with the focus on diabetes and struggled to engage fully with the model. Most participants valued this model of care, which reflects a capacity to manage the variable and complex needs of most patients referred for care. However, multi-level strategies are also needed to enhance patients' engagement with care and the sustainability of integrated diabetes care.

Systematic review of integrated models of health care delivered at the primary-secondary interface: how effective is it and what determines effectiveness?

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary-secondary care. Six elements were identified that were common to these models of integrated primary-secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary-secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

Making sense of change: patients' views of diabetes and GP-led integrated diabetes care

BACKGROUND

Health system reform is directed towards better management of diabetes. However, change can be difficult, and patients' perspectives are a key aspect of implementing change.

OBJECTIVE

This study investigated patients' perceptions and experiences of type 2 diabetes (T2DM), self-care and engagement with GP-led integrated diabetes care.

DESIGN

Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care. Normalization process theory was used to orientate the thematic analysis, to explain the work of implementing change.

SETTING

Two specialist GP-based complex diabetes services in primary care in Brisbane, Australia.

PARTICIPANTS

Intervention group patients (n = 30) in a randomized controlled trial to evaluate a model of GP-led integrated care for complex T2DM.

MAIN OUTCOME MEASURES

Participants' experiences and perceptions of diabetes management and a GP-led model of care.

RESULTS

Three themes were identified: sensibility of change, 'diabetic life' and diabetes care alliance. The imperative of change made sense, but some participants experienced dissonance between this rational view and their lived reality. Diabetes invaded life, revealing incongruities between participants' values and living with diabetes. They appreciated a flexible and personalized approach to care.

DISCUSSION

Participants responded to advice in ways that seemed rational within the complexities of their life context. Their diabetes partnerships with health professionals coupled providers' biomedical expertise with patients' contextual expertise.

CONCLUSIONS

Learning to manage relationships with various health professionals adds to patients' diabetes-related work. Providers need to adopt a flexible, interactive approach and foster trust, to enable better diabetes care.

The work of local healthcare innovation: a qualitative study of GP-led integrated diabetes care in primary health care

BACKGROUND

Service delivery innovation is at the heart of efforts to combat the growing burden of chronic disease and escalating healthcare expenditure. Small-scale, locally-led service delivery innovation is a valuable source of learning about the complexities of change and the actions of local change agents. This exploratory qualitative study captures the perspectives of clinicians and managers involved in a general practitioner-led integrated diabetes care innovation.

METHODS

Data on these change agents' perspectives on the local innovation and how it works in the local context were collected through focus groups and semi-structured interviews at two primary health care sites. Transcribed data were analysed thematically. Normalization Process Theory provided a framework to explore perspectives on the individual and collective work involved in putting the innovation into practice in local service delivery contexts.

RESULTS

Twelve primary health care clinicians, hospital-based medical specialists and practice managers participated in the study, which represented the majority involved in the innovation at the two sites. The thematic analysis highlighted three main themes of local innovation work: 1) trusting and embedding new professional relationships; 2) synchronizing services and resources; and 3) reconciling realities of innovation work. As a whole, the findings show that while locally-led service delivery innovation is designed to respond to local problems, convincing others to trust change and managing the boundary tensions is core to local work, particularly when it challenges taken-for-granted practices and relationships. Despite this, the findings also show that local innovators can and do act in both discretionary and creative ways to progress the innovation.

CONCLUSIONS

The use of Normalization Process Theory uncovered some critical professional, organizational and structural factors early in the progression of the innovation. The key to local service delivery innovation lies in building coalitions of trust at the point of service delivery and persuading organizational and institutional mindsets to consider the opportunities of locally-led innovation.

Brains striving for coherence: Long-term cumulative plot formation in the default mode network

Many everyday activities, such as engaging in conversation or listening to a story, require us to sustain attention over a prolonged period of time while integrating and synthesizing complex episodic content into a coherent mental model. Humans are remarkably capable of navigating and keeping track of all the parallel social activities of everyday life even when confronted with interruptions or changes in the environment. However, the underlying cognitive and neurocognitive mechanisms of such long-term integration and profiling of information remain a challenge to neuroscience. While brain activity is generally traceable within the short time frame of working memory (milliseconds to seconds), these integrative processes last for minutes, hours or even days. Here we report two experiments on story comprehension. Experiment I establishes a cognitive dissociation between our comprehension of plot and incidental facts in narratives: when episodic material allows for long-term integration in a coherent plot, we recall fewer factual details. However, when plot formation is challenged, we pay more attention to incidental facts. Experiment II investigates the neural underpinnings of plot formation. Results suggest a central role for the brain's default mode network related to comprehension of coherent narratives while incoherent episodes rather activate the frontoparietal control network. Moreover, an analysis of cortical activity as a function of the cumulative integration of narrative material into a coherent story reveals to linear modulations of right hemisphere posterior temporal and parietal regions. Together these findings point to key neural mechanisms involved in the fundamental human capacity for cumulative plot formation.

Impact of an integrated model of care on potentially preventable hospitalizations for people with Type 2 diabetes mellitus

AIMS

To evaluate the impact of an integrated model of care for patients with complex Type 2 diabetes mellitus on potentially preventable hospitalizations.

METHODS

A prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. Study and hospital admissions data were linked for the period from 12 months before to 24 months after commencement of the trial. The primary outcome was the number of potentially preventable hospitalizations with diabetes-related principal diagnoses. Length of stay once hospitalized was also reported.

RESULTS

Of 327 adult participants, 206 were hospitalized and accounted for 667 admissions during the study period. Compared with the usual care group, patients in the integrated model of care group were nearly half as likely to be hospitalized for a potentially preventable diabetes-related principal diagnosis in the 24 months after study commencement (incidence rate ratio 0.53, 95% CI 0.29, 0.96; P = 0.04). The magnitude of the result remained similar after adjusting for age, sex, education and baseline HbA1c concentration (incidence rate ratio 0.54, 95% CI 0.29, 1.01; P = 0.05).When hospitalized, patients in the integrated care group had a similar length of stay compared with those in the usual care group (median difference -2 days, 95% CI -6.5, 2.3; P = 0.33).

CONCLUSIONS

Patients receiving the integrated model of care had a reduction in the number of hospitalizations when the principal diagnosis for admission was a diabetes-related complication. Integrated models of care for people with complex diabetes can reduce hospitalizations and help attempts to curtail increasing demand on finite health services.

Association between patient activation and patient-assessed quality of care in type 2 diabetes: results of a longitudinal study

BACKGROUND

Previous research using cross-sectional data has shown a positive relationship between patient activation and quality of care. The quantitative relationships in the same patients over time, however, remain undefined.

OBJECTIVE

To examine the relationship between changes in activation over time and patient-assessed quality of chronic illness care.

DESIGN

Prospective cohort study.

PARTICIPANTS

The study used data reported annually from 2008 (N = 3761) to 2010 (N = 3040), using self-report survey questionnaires, completed by patients with type 2 diabetes in a population-based cohort in Queensland, Australia.

MAIN MEASURES

Principal measures were the 13-item Patient Activation Measure (PAM), and the 20-item Patient Assessment of Chronic Illness Care (PACIC) instrument.

METHODS

Nonparametric anova was used to determine the association between patient activation and patient-assessed quality of care in low and high patient activation groups at baseline (2008), and in 2009 and 2010, when patients had changed group membership. The Wilcoxon signed ranks test was used to compare the PACIC scores between baseline and each follow-up survey for the same patient activation level.

RESULTS

Patient activation was positively associated with the median PACIC score within each survey year and within each of the groups defined at baseline (high- and low-activation groups; P < 0.001).

CONCLUSIONS

Patient activation and the PACIC change in the same direction and should be considered together in the interpretation of patient care assessment. This can be carried out by interpreting PACIC scores within strata of PAM.

Health and social correlates of Internet use for diabetes information: findings from Australia’s Living with Diabetes Study

This study investigated the relationship between online information seeking and a broad range of health and social characteristics among a large sample of Australian adults with type 2 diabetes. One in four participants used the Internet for diabetes-related purposes and Internet searching was associated with high patient activation, poor metabolic control, signs of peripheral nerve damage, a recent diagnosis of diabetes and poorer patient-assessed coordination of care. No relationship was found between Internet use and treatment complexity and the presence of comorbid conditions. The findings underline the importance of providing better online health resources and support to diabetes patients, and of targeting potential intervention points where services and information may be particularly beneficial.

Patient Assessment of Chronic Illness Care (PACIC) in Type 2 Diabetes: A Longitudinal Study

The Patient Assessment of Chronic Illness Care (PACIC) was designed to measure care congruent with several elements of the chronic care model (CCM), including self-management support and delivery system design. However, support for the a priori 5-subscale structure of the PACIC in previous research has been conflicting. Thus, we aim to investigate psychometric characteristics of the PACIC including the content and stability of its construct over time. A population-based prospective cohort study of patients with type 2 diabetes was conducted in Queensland, Australia, from 2008 (N = 3,761) to 2010 (N = 3,040). Participants completed annually the 20-item PACIC as well as measures of providers' adherence to guideline-recommended self-management support activities. We used exploratory factor analysis to determine its factor structure and examined internal consistency as well as agreement between the PACIC at baseline with repeated measurements at follow-up after 1 and 2 years. We also determined a criterion-related validity using multinomial logistic regression to explore PACIC's association with providers' self-management support. A one-factor structure was deemed optimal according to our findings. High internal consistency and moderate agreement within the scales over time were observed. Higher PACIC scores predicted better providers' self-management support. In conclusion, the PACIC is a reliable, valid, and reproducible instrument for assessment of diabetes care, and we recommend its promotion and use as a single scale rather than subscales as originally proposed.

Caseload of a land-based trauma team

BACKGROUND AND AIMS

Pre-hospital care is provided by a variety of models worldwide. The Tayside Trauma Team responds from Ninewells Hospital in Dundee to provide a physician-led pre-hospital care service targeted primarily at trauma patients. We present a description of the functions of the team, and data detailing the clinical work of the Team over a six-month period.

METHODS AND RESULTS

The Team was called out 35 times in six months and attended 22 incidents, some involving multiple casualties. 34 patients received treatment at the scene of an incident. Most incidents were road traffic collisions, although the team also attended falls from height, an assault and a vascular injury. Eight patients (24%) met Injury Severity Score criteria for major trauma (ISS>15). Mean time from 999 calls to Team activation was 20 (range 4-79) min; and mean time from Team dispatch to 'Team mobile' was 4.6 (2-21) min.

CONCLUSION

The Tayside Trauma Team provides a physician-led pre-hospital care response on demand from the Scottish Ambulance Service. It provides critical care interventions at the scene of various incidents (primarily traumatic) to attempt to improve patient outcome. Response times are favourable.

Breast and prostate cancer survivors in a diabetic cohort: results from the Living with Diabetes Study

OBJECTIVE

Diabetes is more common in cancer survivors than in the general population. The objective of the present study was to determine cancer frequency in a cohort of patients with diabetes and to examine demographic, clinical, and quality of life differences between cancer survivors and their cancer-free peers to inform better individualized care.

METHODS

Self-reported survey data from 3,466 registrants with type 2 diabetes from Australia's National Diabetes Services Scheme (NDSS) were analyzed to compare relevant variables between cancer survivors and cancer-free patients. Analyses were focused on breast and prostate cancer to reflect the most common cancers in women and men, respectively.

RESULTS

Five percent of diabetic women reported a history of breast cancer and 4.2% of men reported a history of prostate cancer. Diabetic patients with a history of breast or prostate cancer were older at time of survey and diabetes diagnosis, less likely to report metformin use (women), and more likely to have two or more comorbidities than their cancer-free peers. More diabetic prostate cancer survivors also reported problems with mobility and performing usual tasks. However, cancer-free diabetic subjects reported a lower diabetes-dependent quality of life than diabetic cancer survivors. There was no association between cancer survivorship and duration of diabetes, indices of glycemic control, obesity, or diabetic complications.

CONCLUSIONS

Cancer survivors comprise a significant minority of diabetic patients that are particularly vulnerable and may benefit from interventions to increase screening and treatment of other comorbidities and promote a healthy lifestyle.

A new model of integrated primary-secondary care for complex diabetes in the community: study protocol for a randomised controlled trial

BACKGROUND

A new model of complex diabetes care is provided by a multidisciplinary team which incorporates general practitioner (GP) Clinical Fellows supported by an Endocrinologist and diabetes educator within a community-based general practice setting. This study evaluates the health and clinical benefits of the new model of care, assesses the acceptability of the model to patients, GPs and other health professionals, and examines the cost-effectiveness of the model.

METHODS/DESIGN

The study is an open, non-inferiority randomised controlled trial with data collected at baseline, 6 and 12 months. Participants are identified from new patients on hospital-based diabetes outpatient clinic waiting lists and new GP referrals. Eligible consenting patients are randomised to either a community practice site (intervention) or a hospital site (usual care). In the intervention model, medical care is led by a GP Clinical Fellow in partnership with an Endocrinologist. Quantitative measures include clinical indicators with HbA1c as the primary outcome; patient-reported outcomes include health-related quality of life, mental health and satisfaction with care. Qualitative methods will be used to explore the perspectives and experiences of patients and providers regarding the new model of care. An economic evaluation will also be undertaken.

DISCUSSION

This model of care seeks to improve the quality and safety of healthcare at the interface between the hospital and primary care sectors for patients with complex diabetes. The study will provide empirical evidence about the impact of the model of care on health outcomes, patient and clinician satisfaction, as well as any economic impacts.

TRIAL REGISTRATION

Clinical Trials Registry Number: ACTRN12612000380897.

The impact of concordant and discordant comorbidities on patient-assessed quality of diabetes care

OBJECTIVE

To examine the impact of concordant and discordant comorbidities on patients' assessments of providers' adherence to diabetes-specific care guidelines and quality of chronic illness care.

RESEARCH DESIGN AND METHODS

A population-based survey of 3761 adults with type 2 diabetes, living in Queensland, Australia was conducted in 2008. Based on self-reports, participants were grouped into four mutually exclusive comorbid categories: none, concordant only, discordant only and both concordant and discordant. Outcome measures included patient-reported providers' adherence to guideline-recommended care and the Patient Assessment of Chronic Illness Care (PACIC), which measures care according to the Chronic Care Model. Analyses using the former measure included logistic regressions, and the latter measure included univariate analysis of variance, both unadjusted and adjusted for sampling region, gender, age, educational attainment, diabetes duration and treatment status.

RESULTS

Having concordant comorbidities increased the odds of patient-reported providers' adherence for 7 of the 11 guideline-recommended care activities in unadjusted analyses. However, the effect remained significant for only two provider activities (reviews of medication and/or complications and blood pressure examinations) when adjusted. A similar pattern was found for the both concordant and discordant comorbidity category. The presence of discordant comorbidities influenced only one provider activity (blood pressure examinations). No association between comorbidity type and the overall PACIC score was found.

CONCLUSIONS

Comorbidity type is associated with diabetes-specific care, but does not seem to influence broader aspects of chronic illness care directly. Providers need to place more emphasis on care activities which are not comorbidity-specific and thus transferable across different chronic conditions.

Mental health issues decrease diabetes-specific quality of life independent of glycaemic control and complications: findings from Australia's living with diabetes cohort study

Background

While factors associated with health-related quality of life for people with chronic diseases including diabetes are well researched, far fewer studies have investigated measures of disease-specific quality of life. The purpose of this study is to assess the impact of complications and comorbidities on diabetes-specific quality of life in a large population-based cohort of type 2 diabetic patients.

Methods

The Living with Diabetes Study recruited participants from the National Diabetes Services Scheme in Australia. Data were collected via a mailed self-report questionnaire. Diabetes-specific quality of life was measured using the Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire. The analyses are for 3609 patients with type 2 diabetes. Regression models with adjustment for control variables investigated the association of complications and comorbidities with diabetes-specific quality of life. Next, the most parsimonious model for diabetes-specific quality of life after controlling for important covariates was examined.

Results

The expected associations with better diabetes-specific quality of life were evident, such as increased income, not on insulin, better glycaemic control and older age. However, being single and having been diagnosed with cancer were also associated with better ADDQoL. Additionally, poorer diabetes-specific quality of life was strongly sensitive to the presence of diabetes complications and mental health conditions such as depression, anxiety and schizophrenia. These relationships persisted after adjustment for gender, age, duration of diabetes, treatment regimen, sampling region and other treatment and socio-demographic variables.

Conclusions

A greater appreciation of the complexities of diabetes-specific quality of life can help tailor disease management and self-care messages given to patients. Attention to mental health issues may be as important as focusing on glycaemic control and complications. Therefore clinicians’ ability to identify and mange mental health issues and/or refer patients is critical to improving patients’ diabetes-specific quality of life.

Monte Carlo simulation of the cost-effectiveness of sample size maintenance programs revealed the need to consider substitution sampling

OBJECTIVE

To assess the cost-effectiveness of sample size maintenance programs in a prospective cohort.

STUDY DESIGN AND SETTING

The Living with Diabetes Study in Queensland, Australia is a longitudinal survey providing a comprehensive examination of health care utilization and disease progression among people with diabetes. Data from this study were used to compare the cost-effectiveness of a program incorporating substitution sampling with two alternative programs: "no follow-up" and "usual practice."

RESULTS

A program involving substitution sampling was shown to be the most effective with an additional 3,556 complete responses (compared with a "no follow-up" program) and an additional 2,099 complete responses (compared with "usual practice"). An incremental analysis through a Monte Carlo simulation found substitution sampling to be the most cost-effective option for maintaining sample size with an incremental cost-effective ratio of $54.87 (95% uncertainty interval $52.68-$57.25) compared with $87.58 ($77.89-$100.09) for "usual practice."

CONCLUSIONS

Based on the available data, a program involving substitution sampling is economically justified and should be considered in any approach with the aim of maintaining sample size. There is, however, a continuing need to evaluate the effectiveness of this option on other outcome measures, such as bias.

Being on PAR: Outcomes of a Pilot Trial to Improve Mental Health and Wellbeing in the Workplace With the Promoting Adult Resilience (PAR) Program

There is an urgent need to find strategies to promote positive mental health in the workplace. The current study presents outcomes of a pilot trial of the Promoting Adult Resilience (PAR) program, an innovative mental health promotion program, which is conducted in the workplace over 11 weekly sessions. The PAR program is a strengths-based resilience-building program that integrates interpersonal and cognitive–behaviour therapy (CBT) perspectives. Pre-, post- and follow-up measures on 20 PAR participants from a resource-sector company were compared with a non-intervention-matched comparison group. At follow-up, the PAR group had maintained significant post-test improvements in coping self-efficacy and lower levels of stress and depression, and reported greater work-life fit than the comparison group. The program appeared to be ecologically valid and treatment integrity was maintained. Process evaluations of PAR program showed that skills were rated highly and widely used in everyday life at both post and follow-up measurement times.

Assessing generalisability through the use of disease registers: findings from a diabetes cohort study

Objectives Knowledge of a study population's similarity to the target population allows researchers to assess the generalisability of their results. Often generalisability is assessed through a comparison of baseline characteristics between individuals who did and did not respond to an invitation to participate in a study. In this prospective population-based cohort, we broadened this assessment by comparing participants with all individuals from a chronic disease register who satisfied the study eligibility criteria but for a number of reasons, such as the absence of consent to be approached for research purposes, did not participate. Methods Data are from the Living with Diabetes Study, a population-based cohort of individuals diagnosed with diabetes mellitus, which commenced in Queensland, Australia in 2008. Individuals were sampled from a federally-funded diabetes register. We compared the characteristics of 3951 study participants with 10 488 non-participants (individuals who were invited to participate but declined) and with 129 900 non-study individuals on the register who did not participate in the study. Results Study participants were more likely than non-study registrants to be male, aged 50-69, have type 2 diabetes non-insulin requiring, be recently registered and be non-indigenous Australians. Study participants were more likely than non-participants to be aged 50-69, have type 1 diabetes and be non-indigenous Australians. Conclusions The interpretation of a study's generalisability can alter depending on which non-participating group is compared with participants. When assessing generalisability, participants should be compared with the largest possible group of non-participating individuals. When sampling from a disease register, researchers should be wary of the influence of research consent procedures on the register's coverage.

Hospital admissions, emergency department utilisation and patient activation for self-management among people with diabetes

AIMS

To assess the relationship between patient activation for self-management and admissions to hospital or attendances at emergency departments among people with diabetes, after controlling for other known associations.

METHODS

Patients were randomly selected from Australia's National Diabetes Services Scheme and invited to participate in the Living with Diabetes Study, which is a longitudinal survey providing a comprehensive examination of health care utilisation, well-being and disease progression. Data was collected for 3951 participants.

RESULTS

Outcome events were defined as 1 or more hospitalization and 1 or more visits to an emergency department in the preceding 12 months. Logistic regression analyses showed six variables remained significantly associated with both outcomes: age, income, disease duration and severity, current depression and PAM stage. Patients at PAM stage 1 were 1.4 times more likely to be hospitalised (p=0.023) and 1.3 times more likely to have visited emergency (p=0.049) compared to those at stage 4.

CONCLUSIONS

Low levels of activation are associated with higher utilisation of hospital resources even after controlling for relevant factors such as disease severity and co-morbid depression. Most will be gained by moving patients from PAM stage 1 to a higher level of activation.

The role of patient activation in frequent attendance at primary care: a population-based study of people with chronic disease

OBJECTIVE

This study explores a range of relevant socio-demographic, physical and psychological factors in a unique examination of the risk factors for frequent attendance at primary care. The impact of patient activation for self-management on health service utilisation is of particular interest.

METHODS

A population-based sample of people with chronic disease from Queensland, Australia, was interviewed using computer assisted telephone surveying. Data were collected from a random sample of 1470 people with either diabetes or a cardiovascular condition.

RESULTS

As participants became more activated they were less likely to frequently attend their main health care provider for assistance with their chronic condition. For both conditions the association was graduated and for participants with a cardiovascular condition this association remained statistically significant even after controlling for other potentially influential factors such as disease severity, length of time since diagnosis, and psychological distress.

CONCLUSION

Characteristics of the individual, including patient activation and psychological functioning, as well as disease factors contribute to primary care consulting patterns among people with chronic illness.

PRACTICAL IMPLICATIONS

Efforts to improve patient activation for self-management should remain a central element of chronic care.

Patterns and determinants of influenza and pneumococcal immunisation among adults with chronic disease living in Queensland, Australia

Using findings from a random, computer assisted telephone survey of households, this paper examines influenza and pneumococcal immunisation coverage and predictors of immunisation in 2203 adults with asthma, diabetes or a cardiovascular condition living in Queensland, Australia. 47% and 31% of high-risk persons were immunised against influenza and pneumococcus respectively. Immunisation coverage varied across chronic conditions and increased with age, being significantly higher for those aged 65 years and older and consequently eligible for free vaccination. Poor self reported health status was an independent predictor of pneumococcal vaccination status for people with asthma, diabetes or a cardiovascular condition; however it was only an independent predictor of influenza immunisation status for people with diabetes. Extending free vaccination to all people at risk may increase immunisation rates for younger people with a chronic condition.

Motivational readiness for active commuting by university students: incentives and barriers

ISSUE ADDRESSED

Walking for transport can contribute significantly to health-enhancing physical activity. We examined the associations of stages of motivational readiness for active transport with perceived barriers and incentives to walking to and from university among students.

METHODS

Mail-back surveys were completed by 781 students in a regional university in south-east Queensland. They identified one of eight options on motivational readiness for active commuting, which were then classified as: pre-contemplation; contemplation-preparation; or, action-maintenance. Open-ended questions were used to identify relevant barriers and incentives. Logistic regressions were used to examine the barriers and incentives that distinguished between those at different stages of motivational readiness.

RESULTS

Barriers most frequently reported were long travel distances, inconvenience and time constraints. Incentives most frequently reported were shorter travel distance, having more time, supportive infrastructure and better security. Those not considering active commuting (pre-contemplation) were significantly more likely to report shorter travel distance as an incentive compared to those in contemplation-preparation. Those in contemplation-preparation were significantly more likely to report lack of motivation, inadequate infrastructure, shorter travel distance and inconvenience as barriers; and, having more time, supportive infrastructure, social support and incentive programs as encouragement.

CONCLUSIONS

Different barriers and incentives to walking to or from university exist for students in the different stages of motivational readiness for active commuting. Interventions targeted specifically to stage of motivational readiness may be potentially helpful in increasing activity levels, through active transport.

Residential proximity to school and the active travel choices of parents

ISSUE ADDRESSED

Walking for transport can contribute significantly to health-enhancing physical activity. We examined the prevalence and duration of walking to and from school, together with perceived influences on doing so, among parents of primary school children.

METHODS

Questionnaires were completed by parents from four primary schools (one government and three private) located in south-east Queensland (n=559; 40% response rate).

RESULTS

Eighteen per cent of parents reported walking for at least 10 minutes during journeys to school. Significantly greater proportions of parents with only one car in their household, with a child who attended a government school, with no driver's licence, who had less than 11 years of education, and lived within two kilometres of the school walked for at least 10 minutes during the school journey. Factors perceived by parents most strongly to influence walking to school were: being physically active; safety concerns for the child walking alone; not having to park; walking being the child's preferred option; too much motor vehicle traffic; and their child's age and level of road sense.

CONCLUSIONS

Despite the overall low prevalence of walking to school by parents, health-enhancing benefits may be achieved even when other modes of transport are used in conjunction with walking.

Mental health promotion and non-profit health organisations

Health related non-profit organisations (NPOs) provide a potentially important but largely untapped role in mental health promotion in communities. This paper reports on a study investigating the activities and contributions made by NPOs to mental health and well-being. One hundred and eight NPOs based in the metropolitan area of Brisbane, Queensland, Australia, participated in a survey exploring agency activities that contribute to promoting mental well-being; factors that helped or hindered the organisation in engaging in mental health promotion activities and evaluation methods and processes. An index of key themes was developed and frequencies derived from categorical data. NPOs undertook five key types of activities to promote mental health and well-being: support provision (81%); service provision (59%); information sharing (52%); activities to promote well-being (24%); and advocacy (6%). Systematic evaluation of longer-term outcomes was rare, with most NPOs (72%) relying on informal feedback from clients. Human resources in the form of paid or volunteer workers were most frequently (58%) identified as contributing to the capacity of agencies to carry out mental health promotion activities. Training and education emerged as a substantive need (34%). NPOs are well placed to enhance resiliency in the context of ongoing health problems, disability or other adverse psychosocial circumstances that place people at risk of mental health problems. As such they constitute a significant resource for advancing mental health promotion goals. What is needed to extend the practice and evidence base in this area is training and skill development for NPO workers, along with larger-scale research conducted in collaboration with NPOs to assess the contributions and cost-effectiveness of the sector.

Introduction of an electronic debrief and governance tool in prehospital care

BACKGROUND

The Tayside Trauma Team is a mobile medical team that is deployed from Ninewells Hospital, Dundee, UK at the request of the ambulance service.

AIM

To describe the implementation of a formal debrief and governance tool to ensure the ongoing provision of a high-quality prehospital service.

METHODS

A questionnaire was devised to examine key issues relating to clinical governance and distributed to all members of staff involved in the provision of prehospital care.

RESULTS

A number of areas of concern were revealed, including a lack of understanding on how to report critical incidents occurring in this field and a low level of opportunity to fully discuss events and vocalise concerns. These areas of concern were used to formulate an electronic debrief tool to be available to staff after each incident attended. Reports were considered and actioned and data collected for audit purposes and to provide a framework for discussion at monthly morbidity and mortality meetings.

CONCLUSION

Any patient requiring the services of a healthcare professional in the prehospital setting has a right to expect the same level of quality of care that they would receive within the hospital. The development of a debrief tool will achieve ongoing quality of care in this specialised area of healthcare.

Emergency department management of home intravenous antibiotic therapy for cellulitis

OBJECTIVES

To evaluate the safety and efficacy of using intravenous cephazolin as a first line antibiotic for the treatment of cellulitis in a supervised outpatient programme.

METHODS

This study was a retrospective analysis and included all patients who attended the emergency department (ED) of a university affiliated hospital in Sydney over the period of 1 year and who satisfied the following inclusion criteria: (a) age >16 years, (b) presented with acute cellulitis, and (c) were suitable for home intravenous antibiotic therapy according to APAC guidelines.

RESULTS

In total, 124 patients were included, of whom 53 (42.7%) presented directly to the ED and 71 (57.3%) were referred by their general practitioner. Of these 124 patients, 75 (60.5%) were men and 49 (39.5%) were women. Age range was 16-97 years. There were 82 (66.2%) presentations of cellulitis of the lower limb, 30 (24.2%) of the upper limb, 9 (7.2%) of the face and 3 (2.4%) of the torso. Cephazolin 2 g twice daily was given to 123 (99.2%) of the patients, and one patient (0.8%) received ceftriaxone 2 g once daily. In total, 105 patients (84.7%) were treated successfully and 19 (15.3%) were re-admitted. Four of the unsuccessful treatment group required incision and drainage of abscesses. The mean duration of intravenous therapy was 6.24 days. One patient developed diarrhoea. There were no other complications attributable to therapy.

CONCLUSION

Low re-admission rates verify the efficacy of cephazolin 2 g twice daily in treating cellulitis in the home environment. Benefits are multiple and include economic savings and reduced risk of nosocomial infection.

Risk and protective factors for medically serious suicide attempts: a comparison of hospital-based with population-based samples of young adults

OBJECTIVE

To investigate risk and protective factors for medically serious suicide attempts among young Australian adults.

METHOD

The study used a case-control design. A clinical sample of 18-24 year olds was recruited via the emergency department of a large public hospital following a suicide attempt (n=95) and was compared to a sample of 18-24 year olds who participated in a population-based survey (n=380).

RESULTS

Risk factors for medically serious suicide attempts included early school leaving, parental divorce (males only), distress due to problems with parents (females only), distress due to problems with friends, distress due to the break-up of a romantic relationship, tobacco use, high alcohol use, current depressive symptomatology and a previous diagnosis of depression. Protective factors included social connectedness, problem-solving confidence and locus of control. There was a trend for social connectedness to be more protective among those with high rather than low levels of depressive symptomatology, and among smokers rather than non-smokers.

CONCLUSIONS

Results are discussed in terms of designing evidence-based suicide prevention activities for young adults.