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Marshall KH, Riddiford-Harland DL, Meller AE, Caplan GA, Naganathan V, Cullen J, Gonski P, Zwar NA, O’Keeffe JA, Krysinska K, Rhee JJ. Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences. J Appl Gerontol 2024; 43:339-348. [PMID: 37949095 PMCID: PMC10875901 DOI: 10.1177/07334648231206742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023] Open
Abstract
Guidelines recommend advance care planning (ACP) for people with advanced illness; however, evidence supporting ACP as a component of outpatient care is lacking. We sought to establish the feasibility and acceptability of a facilitated ACP intervention for people attending tertiary outpatient clinics. Data from 20 semi-structured interviews with patient (M = 79.3 ± 7.7, 60% male) and caregiver (M = 68.1 ± 11.0, 60% female) participants recruited as part of a pragmatic, randomized controlled trial (RCT) were analyzed using qualitative descriptive methodology. Patients were randomized to intervention (e.g., facilitated support) or control (e.g., standard care). Intervention patients expressed high satisfaction, reporting the facilitated ACP session was clear, straightforward, and suited to their needs. Intervention caregivers did not report any significant concerns with the facilitated ACP process. Control participants reported greater difficulty completing ACP compared to intervention participants. Embedding facilitated ACP into tertiary outpatient care appears feasible and acceptable for people with advanced illnesses.
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Affiliation(s)
- Kate H. Marshall
- UNSW Academic General Practice Network, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Anne E. Meller
- Advance Care Planning Services, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Gideon A. Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
- Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - John Cullen
- Centre for Education and Research on Ageing (CERA), Department of Geriatric Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Peter Gonski
- Southcare Aged and Extended Community Care, Sutherland Hospital, Sydney, NSW, Australia
| | - Nicholas A. Zwar
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Julie-Ann O’Keeffe
- Aged, Chronic Care and Rehabilitation, Sydney Local Health District, Sydney, NSW, Australia
| | - Karolina Krysinska
- Centre for Primary Health Care and Equity, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Joel J. Rhee
- UNSW Academic General Practice Network, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
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Morphett K, Holland A, Ward S, Steadman KJ, Zwar NA, Gartner C. Evaluating the implementation of a prescription only regulatory model for nicotine vaping products: A qualitative study on the experiences and views of healthcare professionals. Int J Drug Policy 2024; 125:104353. [PMID: 38364356 DOI: 10.1016/j.drugpo.2024.104353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/18/2024] [Accepted: 02/02/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND Deciding how to regulate nicotine vaping products (NVPs) is a challenge for many countries. Balanced regulation should consider the potential harms to young people from uptake of NVPs alongside the possible benefits of NVPs as a smoking cessation aid. One option is to make NVPs only available via medical prescription to adults who smoke. From October 2021, Australia adopted a unique model that allows prescription access to NVPs that meet a product standard without requiring the NVPs to be approved as therapeutic goods. This research explored the impact of this regulatory model on the smoking cessation practices of health professionals, and their views on the model. METHODS Semi-structured interviews were conducted with 39 Australian health professionals recruited from professional networks and social media. Health professionals were eligible if they provided smoking cessation advice as part of their role, and included medical practitioners (n = 9), pharmacists (n = 9), and other health professionals that provided smoking cessation counselling (n = 21). Interviews were mostly completed by phone and online teleconferencing software. Questions focused on smoking cessation practices, advice and information provided to patients about NVPs, views about the effectiveness of the model for supporting use of NVPs for smoking cessation and preventing youth uptake, and barriers and facilitators to prescribing and dispensing NVPs. Coding and analysis used a combination of inductive and deductive approaches. RESULTS Findings indicated a lack of consensus amongst the participants about NVPs as a cessation or harm reduction tool. Participants broadly agreed that the model has not been effective in improving quality control of NVPs, or in reducing youth access. Many participants eligible to prescribe or dispense NVPs felt that the current regulatory model placed an undue time and responsibility burden on clinicians. CONCLUSION Our research identified several limitations associated with the current Australian prescription-only regulatory model. These were perceived by healthcare professionals to limit the potential for the regulations to reduce youth use and to increase access to safer NVP products for people who smoke to use for smoking cessation.
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Affiliation(s)
- Kylie Morphett
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Queensland, Australia.
| | - Alice Holland
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Queensland, Australia
| | - Stephanie Ward
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Queensland, Australia
| | | | - Nicholas A Zwar
- Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Coral Gartner
- NHMRC Centre of Research Excellence on Achieving the Tobacco Endgame, School of Public Health, The University of Queensland, Queensland, Australia
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Freeman B, Peters MJ, Bittoun R, Brightwell R, English DR, Thomas DP, Otlowski MF, Zwar NA, Chamberlain C. National Health and Medical Research Council statement on electronic cigarettes: 2022 update. Med J Aust 2024; 220:100-106. [PMID: 37949610 DOI: 10.5694/mja2.52163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/19/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Electronic cigarette (e-cigarette) use in Australia has rapidly increased since the 2017 National Health and Medical Research Council (NHMRC) Chief Executive Officer (CEO) statement on e-cigarettes. The type of products available and the demographic characteristics of people using these products have changed. New evidence has been published and there is growing concern among public health professionals about the increased use, particularly among young people who do not currently smoke combustible cigarettes. The combination of these issues led NHMRC to review the current evidence and provide an updated statement on e-cigarettes. In this article, we describe the comprehensive process used to review the evidence and develop the 2022 NHMRC CEO statement on electronic cigarettes. MAIN RECOMMENDATIONS E-cigarettes can be harmful; all e-cigarette users are exposed to chemicals and toxins that have the potential to cause adverse health effects. There are no health benefits of using e-cigarettes if you do not currently smoke tobacco cigarettes. Adolescents are more likely to try e-cigarettes if they are exposed to e-cigarettes on social media. Short term e-cigarette use may help some smokers to quit who have been previously unsuccessful with other smoking cessation aids. There are other proven safe and effective options available to help smokers to quit. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT The evidence base for the harms of e-cigarette use has strengthened since the previous NHMRC statement. Significant gaps in the evidence base remain, especially about the longer term health harms of using e-cigarettes and the toxicity of many chemicals in e-cigarettes inhaled as an aerosol.
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Affiliation(s)
| | - Matthew J Peters
- Macquarie University, Sydney, NSW
- Concord Repatriation General Hospital, Sydney, NSW
| | - Renee Bittoun
- Avondale University, Cooranbong, NSW
- University of Notre Dame Australia, Sydney, NSW
| | | | - Dallas R English
- Centre for MEGA Epidemiology, University of Melbourne, Melbourne, VIC
| | - David P Thomas
- Menzies School of Health Research, Charles Darwin University, Darwin, NT
| | | | | | - Catherine Chamberlain
- University of Melbourne, Melbourne, VIC
- Judith Lumley Centre, La Trobe University, Melbourne, VIC
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Stephen C, Halcomb E, Batterham M, McInnes S, Zwar NA. Impact of a general practice nurse intervention to improve blood pressure control: The ImPress study. Aust J Gen Pract 2023; 52:875-881. [PMID: 38049138 DOI: 10.31128/ajgp-09-22-6573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Hypertension is a highly prevalent but often poorly controlled risk factor for cardiovascular disease (CVD). This study examined the effectiveness of a general practice nurse (GPN) intervention to reduce blood pressure in adults with hypertension who are at high risk of CVD. METHOD A cluster randomised control trial was performed across 10 general practices. Systolic (SBP) and diastolic (DBP) blood pressure were evaluated at six and 12 months. RESULTS The adjusted mean difference between intervention and control groups at six months was 8.1 mmHg (95% confidence interval [CI]: -2.92, 18.94 mmHg; P=0.146) for SBP and 0.18 mmHg (95% CI: -6.54, 4.91 mmHg; P=0.775) for DBP. The adjusted mean difference between groups at 12 months was 11.3 mmHg (95% CI: 1.18, 21.42 mmHg; P=0.030) for SBP and 7.1 mmHg (95% CI: -8.62, 22.90 mmHg; P=0.362) for DBP. DISCUSSION Clinically significant between-group differences in mean SBP at six and 12 months provide evidence for GPNs to play a greater role in managing hypertension.
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Affiliation(s)
- Catherine Stephen
- RN, BN (Hons), Lecturer, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW
| | - Elizabeth Halcomb
- RN, BN (Hons), PhD, FACN, Professor of Primary Health Care Nursing, University of Wollongong, Wollongong, NSW
| | - Marijka Batterham
- MSc (Nutr@Diet), MMedStat, PhD, Director, Statistical Consulting Centre, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, NSW
| | - Susan McInnes
- RN, BN (Hons), PhD, Lecturer, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW
| | - Nicholas A Zwar
- MBBS, MPH, PhD, FRACGP, FACTM, Executive Dean @ Health Sciences @ Medicine, Bond University, Robina, Qld
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Glasziou PP, Zwar NA. Commentary on Kraiss et al.: Read the label - improving the applicability of systematic reviews by coding and analysis of intervention elements. Addiction 2023; 118:1851-1852. [PMID: 37612823 PMCID: PMC10952484 DOI: 10.1111/add.16328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Paul P. Glasziou
- Institute for Evidence‐Based HealthcareBond UniversityGold CoastQLDAustralia
| | - Nicholas A. Zwar
- Health Sciences and MedicineBond UniversityGold CoastQLDAustralia
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Perret JL, Zwar NA, Haydn Walters E, Patsamanis H, Abramson MJ, Dharmage SC, Hancock K. A chronic obstructive pulmonary disease risk assessment tool in preventive lung healthcare: An unmet need? Aust J Gen Pract 2023; 52:595-598. [PMID: 37666779 DOI: 10.31128/ajgp-12-22-6653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Jennifer L Perret
- MBBS, FRACP, PhD, NHMRC, Research Fellow, Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic; Affiliate, Institute for Breathing and Sleep (IBAS), Melbourne, Vic; Honorary Respiratory Physician, Austin Health, Melbourne, Vic
| | - Nicholas A Zwar
- MBBS, MPH, PhD, FRACGP, FACTM, Executive Dean, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Qld; Chair, RACGP Travel Medicine Specific Interest Group
| | - E Haydn Walters
- MA, DM, DSc, FRCP, FRACP, FCCP, FThorSoc, Honorary Professorial Fellow in Epidemiology, Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic; Emeritus Professor of Medicine, School of Medicine, University of Tasmania, Hobart, Tas
| | - Harry Patsamanis
- BAppSc, GradCertDiabEd, General Manager Clinical Programs Research and Innovation, Lung Foundation Australia, Milton, Qld
| | - Michael J Abramson
- MB, BS, BMedSc, PhD, FRACP, FAFPHM, FThorSoc, FERS, Professor of Clinical Epidemiology, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic; Honorary Respiratory Physician, The Alfred, Melbourne, Vic
| | - Shyamali C Dharmage
- MBBS, MSc, MD, PhD, FCCPSL, FThorSoc, FERS, NHMRC, Leadership Fellow, Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic
| | - Kerry Hancock
- BMBS, FRACGP (Hon), Chair, Primary Care Clinical Council, Lung Foundation Australia, Milton, Qld; Chair, Respiratory Medicine Network, Specific Interests Faculty, The Royal Australian College of General Practitioners, East Melbourne, Vic; Honorary Fellow, Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic; General Practitioner, Chandlers Hill Surgery, Adelaide, SA
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Hunter DJ, Bowden JL, Hinman RS, Egerton T, Briggs AM, Bunker SJ, French SD, Pirotta M, Shrestha R, Schofield DJ, Schuck K, Zwar NA, Silva SSM, Heller GZ, Bennell KL. Effectiveness of a New Service Delivery Model for Management of Knee Osteoarthritis in Primary Care: A Cluster Randomized Controlled Trial. Arthritis Care Res (Hoboken) 2023; 75:1320-1332. [PMID: 36205225 PMCID: PMC10952211 DOI: 10.1002/acr.25037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/25/2022] [Accepted: 10/04/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and health costs of a new primary care service delivery model (the Optimising Primary Care Management of Knee Osteoarthritis [PARTNER] model) to improve health outcomes for patients with knee osteoarthritis (OA) compared to usual care. METHODS This study was a 2-arm, cluster, superiority, randomized controlled trial with randomization at the general practice level, undertaken in Victoria and New South Wales, Australia. We aimed to recruit 44 practices and 572 patients age ≥45 years with knee pain for >3 months. Professional development opportunities on best practice OA care were provided to intervention group general practitioners (GPs). All recruited patients had an initial GP visit to confirm knee OA diagnosis. Control patients continued usual GP care, and intervention patients were referred to a centralized care support team (CST) for 12-months. Via telehealth, the CST provided OA education and an agreed OA action plan focused on muscle strengthening, physical activity, and weight management. Primary outcomes were patient self-reported change in knee pain (Numerical Rating Scale [range 0-10; higher score = worse]) and physical function (Knee Injury and Osteoarthritis Outcome Score activities of daily living subscale [range 0-100; higher score = better] at 12 months. Health care cost outcomes included costs of medical visits and prescription medications over the 12-month period. RESULTS Recruitment targets were not reached. A total of 38 practices and 217 patients were recruited. The intervention improved pain by 0.8 of 10 points (95% confidence interval [95% CI] 0.2, 1.4) and function by 6.5 of 100 points (95% CI 2.3, 10.7), more than usual care at 12 months. Total costs of medical visits and prescriptions were $3,940 (Australian) for the intervention group versus $4,161 for usual care. This difference was not statistically significant. CONCLUSION The PARTNER model improved knee pain and function more than usual GP care. The magnitude of improvement is unlikely to be clinically meaningful for pain but is uncertain for function.
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Affiliation(s)
- David J. Hunter
- Kolling Institute, The University of Sydney and Royal North Shore HospitalSydneyNew South WalesAustralia
| | - Jocelyn L. Bowden
- Kolling Institute, The University of Sydney and Royal North Shore HospitalSydneyNew South WalesAustralia
| | | | | | | | | | | | - Marie Pirotta
- The University of MelbourneMelbourneVictoriaAustralia
| | | | | | - Karen Schuck
- Kolling Institute, The University of Sydney and Royal North Shore HospitalSydneyNew South WalesAustralia
| | - Nicholas A. Zwar
- University of New South Wales, Sydney, New South Wales, Australia, and Bond UniversityGold CoastQueenslandAustralia
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Ashley C, Williams A, Dennis S, McInnes S, Zwar NA, Morgan M, Halcomb E. Telehealth's future in Australian primary health care: a qualitative study exploring lessons learnt from the COVID-19 pandemic. BJGP Open 2023:BJGPO.2022.0117. [PMID: 36750374 DOI: 10.3399/bjgpo.2022.0117] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/21/2022] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic, telehealth emerged as a means of safely providing primary healthcare (PHC) consultations. In Australia, changes to telehealth funding led to the reconsideration of the role of telehealth in the ongoing provision of PHC services. AIM To investigate GPs', registered nurses' (RNs), nurse practitioners' (NPs), and allied health (AH) clinicians perceptions of the sustainability of telehealth in PHC post-pandemic. DESIGN & SETTING Semi-structured interviews were undertaken with 33 purposively selected clinicians, including GPs (n = 13), RNs (n = 5), NPs (n = 9), and AH clinicians (n = 6) working in PHC settings across Australia. Participants were drawn from responders to a national survey of PHC providers (n = 217). METHOD The thematic analysis approach reported by Braun and Clarke was used to analyse the interview data. RESULTS Data analysis revealed that the perception of providers was represented by the following two themes: lessons learnt; and the sustainability of telehealth. Lessons learnt included the need for rapid adaptation to telehealth, use of technology, and the pandemic being a catalyst for long-term change. The sustainability of telehealth in PHC comprised four subthemes around challenges: the funding model, maintaining patient and provider safety, hybrid service models, and access to support. CONCLUSION Providers required resilience and flexibility to adapt to telehealth. Funding models must reward providers from an outcome focus, rather than placing limits on telehealth's use. Hybrid approaches to service delivery will best meet the needs of the community but must be accompanied by support and education for PHC professionals.
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Affiliation(s)
- Christine Ashley
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia
| | - Anna Williams
- School of Nursing and Midwifery, Western Sydney University, Sydney, Australia
- School of Nursing and Midwifery, University of Notre Dame Australia, Sydney, Australia
| | - Sarah Dennis
- Sydney School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Susan McInnes
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia
| | - Nicholas A Zwar
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Elizabeth Halcomb
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia
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Zwar NA, Leggat PA. International travel in the pandemic era: Implications for health advice. Aust J Gen Pract 2022; 51:879-883. [DOI: 10.31128/ajgp-05-22-6441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Dabscheck E, George J, Hermann K, McDonald CF, McDonald VM, McNamara R, O’Brien M, Smith B, Zwar NA, Yang IA. COPD‐X
Australian guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2022 update. Med J Aust 2022; 217:415-423. [DOI: 10.5694/mja2.51708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/15/2022] [Accepted: 08/02/2022] [Indexed: 11/17/2022]
Affiliation(s)
| | - Johnson George
- Centre for Medicine Use and Safety Monash University Melbourne VIC
| | | | | | | | - Renae McNamara
- Prince of Wales Hospital and Community Health Services Sydney NSW
| | | | | | | | - Ian A Yang
- University of Queensland Brisbane QLD
- Prince Charles Hospital Brisbane QLD
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11
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Wallis KA, Zwar NA, Glasziou PP. Social and occupational outcomes for young people who attend early intervention mental health services: a longitudinal study. Med J Aust 2022; 217:218. [DOI: 10.5694/mja2.51655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/11/2022] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Paul P Glasziou
- Centre for Research in Evidence‐Based Practice Bond University Gold Coast QLD Australia
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Zwar NA, Hasan I, Hayen A, Flynn A, Mullan J, Halcomb EJ, Bonney A. Giving Asthma Support to Patients (GASP) program evaluation. Aust J Gen Pract 2022; 51:257-261. [PMID: 35362013 DOI: 10.31128/ajgp-04-21-5942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVES The Giving Asthma Support to Patients (GASP) program, developed in New Zealand, guides practice nurses to provide structured asthma care. This study assessed GASP in the context of Australian general practice. METHOD The study used a pre-post design and was conducted in 19 practices in Western Sydney and Illawarra/Shoalhaven. Patients aged 5-70 years with moderate-to-severe asthma were invited to participate. Of the 289 patients who attended an initial GASP consultation, 153 attended for one or more follow-up visits. Outcomes were exacerbations requiring medical intervention in the previous 12 months, asthma control in the previous four weeks and quality of asthma care at the time of GASP consultation. RESULTS There was a decrease in patients having one or more exacerbations (113 [74%] versus 80 [52%], P <0.001), and an increase in patients with good asthma control (21 [14%] versus 40 [26%], P <0.005). There was no significant change in the quality of asthma care variable. DISCUSSION Implementation of the GASP program was associated with improvement in asthma outcomes.
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Affiliation(s)
- Nicholas A Zwar
- MBBS, MPH, PhD, FRACGP, Executive Dean, Faculty of Health Sciences and Medicine, Bond University, Qld; Conjoint Professor of General Practice, School of Public Health and Community Medicine, The University of New South Wales, NSW
| | - Iqbal Hasan
- MBBS, MPH, Senior Research Officer, Primary and Integrated Care Unit (PaICU), South Western Sydney Local Health District, NSW Health, Sydney, NSW
| | - Andrew Hayen
- BA (Hons), MBiostat, PhD, Professor of Biostatistics, School of Public Health, University of Technology, Sydney, NSW
| | - Anthony Flynn
- MSocSc, PGDipCritCare, BN, Senior Manager, Research and Evaluation, Asthma Australia, Chatswood, NSW
| | - Judy Mullan
- PhD, FSHPA, BA, BPharm, Academic Director, Centre for Health Research Illawarra Shoalhaven Population (CHRISP) and Deputy Director, Illawarra @ Southern Practice Research Network (ISPRN), School of Medicine, University of Wollongong, Wollongong, NSW
| | - Elizabeth J Halcomb
- RN, BN (Hons), PhD, FACN, Professor of Primary Health Care Nursing, University of Wollongong and Illawarra Health @ Medical Research Institute, Wollongong, NSW
| | - Andrew Bonney
- MBBS, MFM (Clin), PhD, FRACGP, Roberta Williams Chair of General Practice, Graduate School of Medicine, University of Wollongong, Wollongong, NSW; Illawarra Health and Medical Research Institute, Wollongong, NSW
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Courtney RJ, McRobbie H, Tutka P, Weaver NA, Petrie D, Mendelsohn CP, Shakeshaft A, Talukder S, Macdonald C, Thomas D, Kwan BCH, Walker N, Gartner C, Mattick RP, Paul C, Ferguson SG, Zwar NA, Richmond RL, Doran CM, Boland VC, Hall W, West R, Farrell M. Effect of Cytisine vs Varenicline on Smoking Cessation: A Randomized Clinical Trial. JAMA 2021; 326:56-64. [PMID: 34228066 PMCID: PMC8261608 DOI: 10.1001/jama.2021.7621] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Cytisine is more effective than placebo and nicotine replacement therapy for smoking cessation. However, cytisine has not been tested against the most effective smoking cessation medication, varenicline, which is associated with adverse events known to lead to discontinuation of therapy. OBJECTIVE To examine whether standard cytisine treatment (25 days) was at least as effective as standard varenicline treatment (84 days) for smoking cessation. DESIGN, SETTING, AND PARTICIPANTS This noninferiority, open-label randomized clinical trial with allocation concealment and blinded outcome assessment was undertaken in Australia from November 2017 through May 2019; follow-up was completed in January 2020. A total of 1452 Australian adult daily smokers willing to make a quit attempt were included. Data collection was conducted primarily by computer-assisted telephone interview, but there was an in-person visit to validate the primary outcome. INTERVENTIONS Treatments were provided in accordance with the manufacturers' recommended dosage: cytisine (n = 725), 1.5-mg capsules taken 6 times daily initially then gradually reduced over the 25-day course; varenicline (n = 727), 0.5-mg tablets titrated to 1 mg twice daily for 84 days (12 weeks). All participants were offered referral to standard telephone behavioral support. MAIN OUTCOMES AND MEASURES The primary outcome was 6-month continuous abstinence verified using a carbon monoxide breath test at 7-month follow-up. The noninferiority margin was set at 5% and the 1-sided significance threshold was set at .025. RESULTS Among 1452 participants who were randomized (mean [SD] age, 42.9 [12.7] years; 742 [51.1%] women), 1108 (76.3%) completed the trial. Verified 6-month continuous abstinence rates were 11.7% for the cytisine group and 13.3% for the varenicline group (risk difference, -1.62% [1-sided 97.5% CI, -5.02% to ∞]; P = .03 for noninferiority). Self-reported adverse events occurred less frequently in the cytisine group (997 events among 482 participants) compared with the varenicline group (1206 events among 510 participants) and the incident rate ratio was 0.88 (95% CI, 0.81 to 0.95; P = .002). CONCLUSIONS AND RELEVANCE Among daily smokers willing to quit, cytisine treatment for 25 days, compared with varenicline treatment for 84 days, failed to demonstrate noninferiority regarding smoking cessation. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12616001654448.
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Affiliation(s)
- Ryan J. Courtney
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Hayden McRobbie
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Piotr Tutka
- Department of Experimental and Clinical Pharmacology, University of Rzeszow, Rzeszow, Poland
| | - Natasha A. Weaver
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash Business School, Monash University, Clayton, Australia
| | | | - Anthony Shakeshaft
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Saki Talukder
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Christel Macdonald
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Dennis Thomas
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - Benjamin C. H. Kwan
- St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
| | - Natalie Walker
- National Institute for Health Innovation, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Coral Gartner
- School of Public Health, University of Queensland, Herston, Australia
| | - Richard P. Mattick
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Christine Paul
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Stuart G. Ferguson
- Tasmanian School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Nicholas A. Zwar
- Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Robyn L. Richmond
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Christopher M. Doran
- Cluster for Resilience and Wellbeing, Appleton Institute, Central Queensland University, Brisbane, Australia
| | - Veronica C. Boland
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Wayne Hall
- National Centre for Youth Substance Use Research, University of Queensland, Herston, Australia
| | - Robert West
- Department of Behavioural Science and Health, University College London, London, England
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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Sweetman A, Zwar NA, Grivell N, Lovato N, Lack L. A step-by-step model for a brief behavioural treatment for insomnia in Australian general practice. Aust J Gen Pract 2021; 50:287-293. [PMID: 33928277 DOI: 10.31128/ajgp-04-20-5391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic insomnia is a prevalent and debilitating disorder managed in Australian general practice. The most effective and recommended first-line treatment for insomnia is cognitive behavioural therapy. This treatment has been translated to a condensed brief behavioural therapy for insomnia (BBTi), which is suitable for delivery in the general practice setting. There is evidence that BBTi improves insomnia, daytime functioning and quality of life, with effects persisting far beyond treatment cessation. BBTi appears to be a cost-effective treatment that is superior to sedative-hypnotic management. OBJECTIVE The aim of this article is to present a step-by-step approach for Australian general practitioners to administer BBTi. DISCUSSION BBTi is an effective treatment for insomnia that may be administered in the Australian general practice setting. General practitioners may choose to use existing funding support to administer BBTi to treat chronic insomnia according to guideline recommendations.
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Affiliation(s)
- Alexander Sweetman
- PhD, Research Associate, Adelaide Institute for Sleep Health (AISH): A Centre of Research Excellence, College of Medicine and Public Health, Flinders University, SA; Research Associate, National Centre for Sleep Health Services Research (NCSHSR): An NHMRC Centre of Research Excellence, Flinders University, SA
| | - Nicholas A Zwar
- MBBS, MPH, PhD, FRACGP, Executive Dean, Faculty of Health Sciences and Medicine, Bond University, Qld; Conjoint Professor of General Practice, School of Public Health and Community Medicine, The University of New South Wales, NSW
| | - Nicole Grivell
- AISH, College of Medicine and Public Health, Flinders University, SA; NCSHSR, Flinders University, SA
| | - Nicole Lovato
- PhD, Senior Research Fellow, AISH, College of Medicine and Public Health, Flinders University, SA; Senior Research Fellow, NCSHSR, Flinders University, SA
| | - Leon Lack
- PhD, Senior Researcher, AISH, College of Education, Psychology and Social Work, Flinders University, SA; Senior Researcher, NCSHSR, Flinders University, SA
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Abstract
BACKGROUND Although Australia is a world leader in tobacco control, smoking remains the behavioural risk factor making the largest contribution to death and disease. Smoking rates remain high in Aboriginal and Torres Strait Islander people and in people with mental health problems. Priority groups for cessation include women who are pregnant and people with cardiovascular disease. OBJECTIVE This article, based on the recently published second edition of Supporting smoking cessation: A guide for health professionals, provides an update on current evidence-based practice to support quitting. A brief, time-efficient intervention approach (Ask, Advise, Help) is proposed. New approaches to the use of pharmacotherapy are covered, as is the controversial role of nicotine-containing e-cigarettes and advice for groups with high smoking prevalence and those with special needs. DISCUSSION A combination of behavioural support along with pharmacotherapy to treat nicotine dependence maximises the chances of successful long-term cessation. Combination nicotine replacement therapy (patch and short-acting oral form) or varenicline are the most effective forms of pharmacotherapy.
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Affiliation(s)
- Nicholas A Zwar
- MBBS, MPH, PhD, FRACGP, Executive Dean, Faculty of Health Sciences and Medicine, Bond University, Qld; Conjoint Professor of General Practice, School of Public Health and Community Medicine, The University of New South Wales, NSW
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16
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Gattellari M, Hayen A, Leung DYC, Zwar NA, Worthington JM. Supporting anticoagulant treatment decision making to optimise stroke prevention in complex patients with atrial fibrillation: a cluster randomised trial. BMC Fam Pract 2020; 21:102. [PMID: 32513116 PMCID: PMC7281948 DOI: 10.1186/s12875-020-01175-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2020] [Indexed: 12/15/2022]
Abstract
Background Anticoagulation for preventing stroke in atrial fibrillation is under-utilised despite evidence supporting its use, resulting in avoidable death and disability. We aimed to evaluate an intervention to improve the uptake of anticoagulation. Methods We carried out a national, cluster randomised controlled trial in the Australian primary health care setting. General practitioners received an educational session, delivered via telephone by a medical peer and provided information about their patients selected either because they were not receiving anticoagulation or for whom anticoagulation was considered challenging. General practitioners were randomised to receive feedback from a medical specialist about the cases (expert decisional support) either before or after completing a post-test audit. The primary outcome was the proportion of patients reported as receiving oral anticoagulation. A secondary outcome assessed antithrombotic treatment as appropriate against guideline recommendations. Results One hundred and seventy-nine general practitioners participated in the trial, contributing information about 590 cases. At post-test, 152 general practitioners (84.9%) completed data collection on 497 cases (84.2%). A 4.6% (Adjusted Relative Risk = 1.11, 95% CI = 0.86–1.43) difference in the post-test utilization of anticoagulation between groups was not statistically significant (p = 0.42). Sixty-one percent of patients in both groups received appropriate antithrombotic management according to evidence-based guidelines at post-test (Adjusted Relative Risk = 1.0; 95% CI = 0.85 to 1.19) (p = 0.97). Conclusions Specialist feed-back in addition to an educational session did not increase the uptake of anticoagulation in patients with AF. Trial registration ANZCTRN12611000076976 Retrospectively registered.
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Affiliation(s)
- Melina Gattellari
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia. .,Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, New South Wales, 2170, Australia.
| | - Andrew Hayen
- Faculty of Health, University of Technology Sydney, 15 Broadway, Ultimo, New South Wales, 2007, Australia
| | - Dominic Y C Leung
- South Western Sydney Clinical School UNSW, Liverpool, Australia.,Department of Cardiology, Liverpool Health Service, Sydney South West Local Health District, Clinical Services Building, Elizabeth Street, Liverpool (Sydney), New South Wales, 2170, Australia
| | - Nicholas A Zwar
- Faculty of Health, Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - John M Worthington
- Department of Neurology, Institute for Clinical Neurosciences, Neuroscience Research, Royal Prince Alfred Hospital, Missenden Road, Sydney Local Health District, Camperdown (Sydney), New South Wales, 2050, Australia.,South Western Sydney Clinical School UNSW, Liverpool, Australia
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17
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18
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Bowden JL, Egerton T, Hinman RS, Bennell KL, Briggs AM, Bunker SJ, Kasza J, French SD, Pirotta M, Schofield DJ, Zwar NA, Hunter DJ. Protocol for the process and feasibility evaluations of a new model of primary care service delivery for managing pain and function in patients with knee osteoarthritis (PARTNER) using a mixed methods approach. BMJ Open 2020; 10:e034526. [PMID: 32024793 PMCID: PMC7045031 DOI: 10.1136/bmjopen-2019-034526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This protocol outlines the rationale, design and methods for the process and feasibility evaluations of the primary care management on knee pain and function in patients with knee osteoarthritis (PARTNER) study. PARTNER is a randomised controlled trial to evaluate a new model of service delivery (the PARTNER model) against 'usual care'. PARTNER is designed to encourage greater uptake of key evidence-based non-surgical treatments for knee osteoarthritis (OA) in primary care. The intervention supports general practitioners (GPs) to gain an understanding of the best management options available through online professional development. Their patients receive telephone advice and support for OA management by a centralised, multidisciplinary 'Care Support Team'. We will conduct concurrent process and feasibility evaluations to understand the implementation of this new complex health intervention, identify issues for consideration when interpreting the effectiveness outcomes and develop recommendations for future implementation, cost effectiveness and scalability. METHODS AND ANALYSIS The UK Medical Research Council Framework for undertaking a process evaluation of complex interventions and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) frameworks inform the design of these evaluations. We use a mixed-methods approach including analysis of survey data, administrative records, consultation records and semistructured interviews with GPs and their enrolled patients. The analysis will examine fidelity and dose of the intervention, observations of trial setup and implementation and the quality of the care provided. We will also examine details of 'usual care'. The semistructured interviews will be analysed using thematic and content analysis to draw out themes around implementation and acceptability of the model. ETHICS AND DISSEMINATION The primary and substudy protocols have been approved by the Human Research Ethics Committee of The University of Sydney (2016/959 and 2019/503). Our findings will be disseminated to national and international partners and stakeholders, who will also assist with wider dissemination of our results across all levels of healthcare. Specific findings will be disseminated via peer-reviewed journals and conferences, and via training for healthcare professionals delivering OA management programmes. This evaluation is crucial to explaining the PARTNER study results, and will be used to determine the feasibility of rolling-out the intervention in an Australian healthcare context. TRIAL REGISTRATION NUMBER ACTRN12617001595303; Pre-results.
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Affiliation(s)
- Jocelyn L Bowden
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, St Leonards, New South Wales, Australia
- Department of Rheumatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Thorlene Egerton
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rana S Hinman
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kim L Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Perth, Western Australia, Australia
| | | | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Simon D French
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - Marie Pirotta
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah J Schofield
- Centre for Economic Impacts of Genomic Medicine, Macquarie Business School, Macquarie University, Sydney, New South Wales, Australia
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - David J Hunter
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, St Leonards, New South Wales, Australia
- Department of Rheumatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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19
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Izbicki G, Teo V, Liang J, Russell GM, Holland AE, Zwar NA, Bonevski B, Mahal A, Eustace P, Paul E, Phillips K, Wilson S, George J, Abramson MJ. Clinical Characteristics Of Patients With Asthma COPD Overlap (ACO) In Australian Primary Care. Int J Chron Obstruct Pulmon Dis 2019; 14:2745-2752. [PMID: 31819406 PMCID: PMC6899160 DOI: 10.2147/copd.s220346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/31/2019] [Indexed: 12/30/2022] Open
Abstract
Purpose Many older adults with a history of smoking and asthma develop clinical features of both asthma and COPD, an entity sometimes called asthma-COPD overlap (ACO). Patients with ACO may be at higher risk of poor health outcomes than those with asthma or COPD alone. However, understanding of ACO is limited in the primary care setting and more information is needed to better inform patient management. We aimed to compare the characteristics of patients with ACO or COPD in Australian general practices. Patients and methods Data were from the RADICALS (Review of Airway Dysfunction and Interdisciplinary Community-based care of Adult Long-term Smokers) trial, an intervention study of an interdisciplinary community-based model of care. Baseline demographic and clinical characteristics, pre- and post-bronchodilator spirometry, dyspnoea and St. George’s Respiratory Questionnaire scores were compared between 60 ACO patients and 212 with COPD alone. Results Pre-bronchodilator Forced Expiratory Volume in 1 second (mean±SD 58.4±14.3 vs 67.5±20.1% predicted) and Forced Vital Capacity (mean 82.1±16.9 v 91.9±17.2% predicted) were significantly lower in the ACO group (p<0.001), but no difference was found in post-bronchodilator spirometry. Demographic and clinical characteristics, dyspnoea, quality of life, comorbidities and treatment prescribed did not differ significantly between groups. Conclusion This is the first study describing the clinical characteristics of ACO patients in Australian general practices. Our finding of lower pre-bronchodilator lung function in the ACO group compared to those with COPD reinforces the importance of spirometry in primary care to inform management. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614001155684.
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Affiliation(s)
- Gabriel Izbicki
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Shaare Zedek Medical Center and The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Valerie Teo
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,National Healthcare Group Polyclinics, Singapore
| | - Jenifer Liang
- Centre For Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Grant M Russell
- Southern Academic Primary Care Research Unit, Department of General Practice, Monash University, Notting Hill, Australia
| | - Anne E Holland
- Discipline of Physiotherapy, La Trobe University and Alfred Health, Melbourne, Australia
| | - Nicholas A Zwar
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia
| | - Billie Bonevski
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Ajay Mahal
- The Nossal Institute For Global Health, University of Melbourne, Melbourne, Australia
| | | | - Eldho Paul
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Sally Wilson
- Centre For Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia.,Department of Infrastructure Engineering, The University of Melbourne, Melbourne, Australia
| | - Johnson George
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Centre For Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Michael J Abramson
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
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Liang J, Abramson MJ, Russell G, Holland AE, Zwar NA, Bonevski B, Mahal A, Eustace P, Paul E, Phillips K, Cox NS, Wilson S, George J. Interdisciplinary COPD intervention in primary care: a cluster randomised controlled trial. Eur Respir J 2019; 53:13993003.01530-2018. [PMID: 30792342 DOI: 10.1183/13993003.01530-2018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/25/2019] [Indexed: 12/31/2022]
Abstract
We evaluated the effectiveness of an interdisciplinary, primary care-based model of care for chronic obstructive pulmonary disease (COPD).A cluster randomised controlled trial was conducted in 43 general practices in Australia. Adults with a history of smoking and/or COPD, aged ≥40 years with two or more clinic visits in the previous year were enrolled following spirometric confirmation of COPD. The model of care comprised smoking cessation support, home medicines review (HMR) and home-based pulmonary rehabilitation (HomeBase). Main outcomes included changes in St George's Respiratory Questionnaire (SGRQ) score, COPD Assessment Test (CAT), dyspnoea, smoking abstinence and lung function at 6 and 12 months.We identified 272 participants with COPD (157 intervention, 115 usual care); 49 (31%) out of 157 completed both HMR and HomeBase. Intention-to-treat analysis showed no statistically significant difference in change in SGRQ at 6 months (adjusted between-group difference 2.45 favouring intervention, 95% CI -0.89-5.79). Per protocol analyses showed clinically and statistically significant improvements in SGRQ in those receiving the full intervention compared to usual care (difference 5.22, 95% CI 0.19-10.25). No statistically significant differences were observed in change in CAT, dyspnoea, smoking abstinence or lung function.No significant evidence was found for the effectiveness of this interdisciplinary model of care for COPD in primary care over usual care. Low uptake was a limitation.
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Affiliation(s)
- Jenifer Liang
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Michael J Abramson
- Dept of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Grant Russell
- Southern Academic Primary Care Research Unit, Dept of General Practice, Monash University, Melbourne, Australia
| | - Anne E Holland
- Discipline of Physiotherapy, La Trobe University, Alfred Health, and Institute for Breathing and Sleep, Melbourne, Australia
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Billie Bonevski
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Ajay Mahal
- The Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | | | - Eldho Paul
- Dept of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Narelle S Cox
- Discipline of Physiotherapy, La Trobe University and Institute for Breathing and Sleep, Melbourne, Australia
| | - Sally Wilson
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia.,Dept of Infrastructure Engineering, The University of Melbourne, Melbourne, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia .,Dept of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Laba TL, Jan S, Zwar NA, Roughead E, Marks GB, Flynn AW, Goldman MD, Heaney A, Lembke KA, Reddel HK. Cost-Related Underuse of Medicines for Asthma-Opportunities for Improving Adherence. J Allergy Clin Immunol Pract 2019; 7:2298-2306.e12. [PMID: 30928659 DOI: 10.1016/j.jaip.2019.03.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/24/2019] [Accepted: 03/14/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND In asthma, underuse of cost-effective preventive treatments increases morbidity and mortality. The cost of medicines contributes to underuse ("nonadherence"), but the extent to which people with asthma skip or reduce doses or let prescriptions go unfilled when faced with cost pressures is unknown. OBJECTIVE To estimate the extent of cost-related underuse behaviors and associated factors. METHODS Using previously validated summary indicators, we conducted an online cross-sectional survey of adults and parents of children 5 to 17 years with asthma in Australia (a high-income country) and developed logistic regression models for adults and children with asthma, controlling for key clinical and demographic factors. RESULTS The survey was completed by n = 792 adults (mean age, 47 [standard deviation, 17] years, male 47%, concession 60%) and n = 609 parents of children (5-10 years 51%, male 60%, concession 59%) with asthma. Cost-related underuse was reported by 52.9% adults and 34.3% parents, predominantly decreasing or skipping doses to make medicines last longer. Higher odds of cost-related underuse were observed with younger adults (adults: odds ratio [OR]: 1.19; 95% confidence interval [CI]: 1.12, 1.27), males (adults: OR: 1.49; 95% CI: 1.06, 2.08), having concerns about medicines (adults: OR: 3.12; 95% CI: 2.17, 4.35; parents: OR: 2.63; 95% CI: 1.56, 4.55), less comfortable talking to prescribers about cost (parents: OR: 1.22; 95% CI: 1.12, 1.33) or changing medicines (adults: OR: 1.12; 95% CI: 1.03, 1.22), feeling less engaged with prescribers about medicine decisions (parents: OR: 1.11; 95% CI: 1.01, 1.23), and with poorer asthma control (adults, poor control: OR: 1.87; 95% CI: 1.13, 3.09; parents, poor control: OR: 3.87; 95% CI: 1.99, 7.54), and requiring specialist (parents: OR: 1.83; 95% CI: 1.16, 2.87) or urgent health care visits (adults: OR: 1.54; 95% CI: 1.06, 2.23). Income and concession card status were not associated with cost-related underuse. CONCLUSIONS Adults and parents of children with asthma indicate high rates of cost-related underuse of asthma medicines, even in the context of national medicines subsidies. Urgent targeting of interventions to promote discussion of medicines and costs between doctor and patients, particularly young adult males, is needed.
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Affiliation(s)
- Tracey-Lea Laba
- Faculty of Medicine and Health, Menzies Centre for Health Policy, School of Public Health, The University of Sydney, Camperdown, Australia; The George Institute for Global Health, University of New South Wales, Newtown, Australia.
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Newtown, Australia
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Randwick, Australia; Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Anthony W Flynn
- Asthma Foundation Queensland and New South Wales, now part of Asthma Australia Limited, Chatswood, Australia
| | - Michele D Goldman
- Asthma Foundation Queensland and New South Wales, now part of Asthma Australia Limited, Chatswood, Australia
| | - Aine Heaney
- Department of Program Design, NPS MedicineWise, Sydney, Australia
| | - Kirsty A Lembke
- Department of Program Design, NPS MedicineWise, Sydney, Australia
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
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22
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Liang J, Abramson MJ, Zwar NA, Russell GM, Holland AE, Bonevski B, Mahal A, Phillips K, Eustace P, Paul E, Wilson S, George J. Diagnosing COPD and supporting smoking cessation in general practice: evidence-practice gaps. Med J Aust 2018; 208:29-34. [PMID: 29320670 DOI: 10.5694/mja17.00664] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/15/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To review the accuracy of diagnoses of chronic obstructive pulmonary disease (COPD) in primary care in Australia, and to describe smokers' experiences with and preferences for smoking cessation. DESIGN, SETTING AND PARTICIPANTS Patients were invited to participate if they were at least 40 years old and had visited participating general practice clinics in Melbourne at least twice during the previous 12 months, reported being current or ex-smokers with a smoking history of at least 10 pack-years, or were being managed for COPD. Interviews based on a structured questionnaire and case finding (FEV1/FEV6 measurement) were followed, when appropriate, by spirometry testing and assessment of health-related quality of life, dyspnoea and symptoms. RESULTS 1050 patients attended baseline interviews (February 2015 - April 2017) at 41 practices. Of 245 participants managed for COPD, 130 (53.1%) met the spirometry-based definition (post-bronchodilator FEV1/FVC < 0.7) or had a clinical correlation; in 37% of cases COPD was not confirmed, and no definitive result was obtained for 9.8% of patients. Case finding and subsequent spirometry testing identified 142 new COPD cases (17.6% of participants without prior diagnosis; 95% CI, 15.1-20.5%). 690 participants (65.7%) were current smokers, of whom 360 had attempted quitting during the previous 12 months; 286 (81.0% of those attempting to quit) reported difficulties during previous quit attempts. Nicotine replacement therapy (205, 57.4%) and varenicline (110, 30.8%) were the most frequently employed pharmacological treatments; side effects were common. Hypnotherapy was the most popular non-pharmacological option (62 smokers, 17%); e-cigarettes were tried by 38 (11%). 187 current smokers (27.6%) would consider using e-cigarettes in future attempts to quit. CONCLUSIONS COPD was both misdiagnosed and missed. Case finding and effective use of spirometry testing could improve diagnosis. Side effects of smoking cessation medications and difficulties during attempts to quit smoking are common. Health professionals should emphasise evidence-based treatments, and closely monitor quitting difficulties and side effects of cessation aids. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12614001155684.
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Affiliation(s)
- Jenifer Liang
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
| | | | | | - Grant M Russell
- Southern Academic Primary Care Research Unit, Monash University, Melbourne, VIC
| | | | | | | | | | | | | | - Sally Wilson
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
| | - Johnson George
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
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Hunter DJ, Hinman RS, Bowden JL, Egerton T, Briggs AM, Bunker SJ, Kasza J, Forbes AB, French SD, Pirotta M, Schofield DJ, Zwar NA, Bennell KL. Correction to: Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY. BMC Musculoskelet Disord 2018; 19:443. [PMID: 30572871 PMCID: PMC6302386 DOI: 10.1186/s12891-018-2362-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
After the publication of this protocol [1], our collaborator Prima Health solutions advised us of their intent to withdraw from the study.
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Affiliation(s)
- D J Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia. .,Department of Rheumatology, Royal North Shore Hospital, Sydney, NSW, Australia.
| | - R S Hinman
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - J L Bowden
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia
| | - T Egerton
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - A M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
| | - S J Bunker
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - J Kasza
- Biostatistics Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - A B Forbes
- Biostatistics Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - S D French
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada.,Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, NSW, Australia
| | - M Pirotta
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - D J Schofield
- Department of Economics, Faculty of Business and Economics, Macquarie University, Sydney, Australia
| | - N A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia.,School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - K L Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
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Brieger D, Amerena J, Attia JR, Bajorek B, Chan KH, Connell C, Freedman B, Ferguson C, Hall T, Haqqani HM, Hendriks J, Hespe CM, Hung J, Kalman JM, Sanders P, Worthington J, Yan T, Zwar NA. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the diagnosis and management of atrial fibrillation 2018. Med J Aust 2018; 209:356-362. [DOI: 10.5694/mja18.00646] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 10/12/2018] [Indexed: 02/02/2023]
Affiliation(s)
| | | | - John R Attia
- University of Newcastle, Newcastle, NSW
- John Hunter Hospital, Newcastle, NSW
| | | | - Kim H Chan
- Royal Prince Alfred Hospital, Sydney, NSW
- University of Sydney, Sydney, NSW
| | - Cia Connell
- National Heart Foundation of Australia, Melbourne, VIC
| | | | - Caleb Ferguson
- Western Sydney University, Sydney, NSW
- Blacktown and Mount Druitt Hospital, Sydney, NSW
| | | | | | - Jeroen Hendriks
- Royal Adelaide Hospital, Adelaide, SA
- University of Adelaide, Adelaide
| | | | | | - Jonathan M Kalman
- University of Melbourne, Melbourne, VIC
- Royal Melbourne Hospital, Melbourne, VIC
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25
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Hunter DJ, Hinman RS, Bowden JL, Egerton T, Briggs AM, Bunker SJ, Kasza J, Forbes AB, French SD, Pirotta M, Schofield DJ, Zwar NA, Bennell KL. Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY. BMC Musculoskelet Disord 2018; 19:132. [PMID: 29712564 PMCID: PMC5928565 DOI: 10.1186/s12891-018-2048-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 04/16/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND To increase the uptake of key clinical recommendations for non-surgical management of knee osteoarthritis (OA) and improve patient outcomes, we developed a new model of service delivery (PARTNER model) and an intervention to implement the model in the Australian primary care setting. We will evaluate the effectiveness and cost-effectiveness of this model compared to usual general practice care. METHODS We will conduct a mixed-methods study, including a two-arm, cluster randomised controlled trial, with quantitative, qualitative and economic evaluations. We will recruit 44 general practices and 572 patients with knee OA in urban and regional practices in Victoria and New South Wales. The interventions will target both general practitioners (GPs) and their patients at the practice level. Practices will be randomised at a 1:1 ratio. Patients will be recruited if they are aged ≥45 years and have experienced knee pain ≥4/10 on a numerical rating scale for more than three months. Outcomes are self-reported, patient-level validated measures with the primary outcomes being change in pain and function at 12 months. Secondary outcomes will be assessed at 6 and 12 months. The implementation intervention will support and provide education to intervention group GPs to deliver effective management for patients with knee OA using tailored online training and electronic medical record support. Participants with knee OA will have an initial GP visit to confirm their diagnosis and receive management according to GP intervention or control group allocation. As part of the intervention group GP management, participants with knee OA will be referred to a centralised multidisciplinary service: the PARTNER Care Support Team (CST). The CST will be trained in behaviour change support and evidence-based knee OA management. They will work with patients to develop a collaborative action plan focussed on key self-management behaviours, and communicate with the patients' GPs. Patients receiving care by intervention group GPs will receive tailored OA educational materials, a leg muscle strengthening program, and access to a weight-loss program as appropriate and agreed. GPs in the control group will receive no additional training and their patients will receive usual care. DISCUSSION This project aims to address a major evidence-to-practice gap in primary care management of OA by evaluating a new service delivery model implemented with an intervention targeting GP practice behaviours to improve the health of people with knee OA. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12617001595303 , date of registration 1/12/2017.
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Affiliation(s)
- David J. Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia
- Department of Rheumatology, Royal North Shore Hospital, Sydney, NSW Australia
| | - Rana S. Hinman
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria Australia
| | - Jocelyn L. Bowden
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia
| | - Thorlene Egerton
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria Australia
| | - Andrew M. Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Perth, WA Australia
| | - Stephen J. Bunker
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria Australia
| | - Jessica Kasza
- Biostatistics Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria Australia
| | - Andrew B. Forbes
- Biostatistics Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria Australia
| | - Simon D. French
- School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario Canada
- Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, NSW Australia
| | - Marie Pirotta
- Department of General Practice, The University of Melbourne, Melbourne, Victoria Australia
| | - Deborah J. Schofield
- Department of Economics, Faculty of Business and Economics, Macquarie University, Sydney, NSW 2109 Australia
| | - Nicholas A. Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW Australia
- School of Medicine, University of Wollongong, Wollongong, NSW Australia
| | - Kim L. Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria Australia
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26
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Zwar NA, Dennis SM. Self‐management support for patients with chronic disease: potential and questions. Med J Aust 2018; 208:66-67. [DOI: 10.5694/mja17.01002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/03/2017] [Indexed: 11/17/2022]
Affiliation(s)
| | - Sarah M Dennis
- University of Sydney, Sydney, NSW
- Ingham Institute of Applied Medical Research, Sydney, NSW
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27
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Yang IA, Brown JL, George J, Jenkins S, McDonald CF, McDonald VM, Phillips K, Smith BJ, Zwar NA, Dabscheck E. COPD‐X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update. Med J Aust 2017; 207:436-442. [DOI: 10.5694/mja17.00686] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/07/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Ian A Yang
- University of Queensland, Brisbane, QLD
- Prince Charles Hospital, Brisbane, QLD
| | - Juliet L Brown
- COPD National Program, Lung Foundation Australia, Brisbane, QLD
| | - Johnson George
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
| | - Sue Jenkins
- Curtin University, Perth, WA
- Sir Charles Gairdner Hospital, Perth, WA
| | | | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW
- John Hunter Hospital, Newcastle, NSW
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28
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Chalasani S, Peiris DP, Usherwood T, Redfern J, Neal BC, Sullivan DR, Colagiuri S, Zwar NA, Li Q, Patel A. Reducing cardiovascular disease risk in diabetes: a randomised controlled trial of a quality improvement initiative. Med J Aust 2017; 206:436-441. [DOI: 10.5694/mja16.00332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 12/13/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Santhi Chalasani
- The George Institute for International Health, University of Sydney, Sydney, NSW
| | - David P Peiris
- The George Institute for International Health, University of Sydney, Sydney, NSW
| | - Tim Usherwood
- Sydney Medical School, University of Sydney, Sydney, NSW
| | - Julie Redfern
- The George Institute for International Health, University of Sydney, Sydney, NSW
- Sydney Medical School, University of Sydney, Sydney, NSW
| | - Bruce C Neal
- The George Institute for International Health, University of Sydney, Sydney, NSW
| | | | - Stephen Colagiuri
- Boden Institute of Obesity, Nutrition and Exercise, University of Sydney, Sydney, NSW
- UNSW Australia, Sydney, NSW
| | | | - Qiang Li
- The George Institute for International Health, University of Sydney, Sydney, NSW
| | - Anushka Patel
- The George Institute for International Health, University of Sydney, Sydney, NSW
- Sydney Medical School, University of Sydney, Sydney, NSW
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29
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Gabb GM, Mangoni AA, Anderson CS, Cowley D, Dowden JS, Golledge J, Hankey GJ, Howes FS, Leckie L, Perkovic V, Schlaich M, Zwar NA, Medley TL, Arnolda L. Guideline for the diagnosis and management of hypertension in adults - 2016. Med J Aust 2017; 205:85-9. [PMID: 27456450 DOI: 10.5694/mja16.00526] [Citation(s) in RCA: 187] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The National Heart Foundation of Australia has updated the Guide to management of hypertension 2008: assessing and managing raised blood pressure in adults (updated December 2010). Main recommendations For patients at low absolute cardiovascular disease risk with persistent blood pressure (BP) ≥ 160/100 mmHg, start antihypertensive therapy. The decision to treat at lower BP levels should consider absolute cardiovascular disease risk and/or evidence of end-organ damage, together with accurate BP assessment. For patients at moderate absolute cardiovascular disease risk with persistent systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, start antihypertensive therapy. Treat patients with uncomplicated hypertension to a target BP of < 140/90 mmHg or lower if tolerated. Changes in management as a result of the guideline Ambulatory and/or home BP monitoring should be offered if clinic BP is ≥ 140/90 mmHg, as out-of-clinic BP is a stronger predictor of outcome. In selected high cardiovascular risk populations, aiming for a target of < 120 mmHg systolic can improve cardiovascular outcomes. If targeting < 120 mmHg, close follow-up is recommended to identify treatment-related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury. Why the changes have been made A 2015 meta-analysis of patients with uncomplicated mild hypertension (systolic BP range, 140-169 mmHg) demonstrated that BP-lowering therapy is beneficial (reduced stroke, cardiovascular death and all-cause mortality). A 2015 trial comparing lower with higher blood pressure targets in selected high cardiovascular risk populations found improved cardiovascular outcomes and reduced mortality, with an increase in some treatment-related adverse events.
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Affiliation(s)
| | | | | | | | | | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University, Townsville, QLD
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30
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Zwar NA, Bunker JM, Reddel HK, Dennis SM, Middleton S, van Schayck OCP, Crockett AJ, Hasan I, Hermiz O, Vagholkar S, Xuan W, Marks GB. Early intervention for chronic obstructive pulmonary disease by practice nurse and GP teams: a cluster randomized trial. Fam Pract 2016; 33:663-670. [PMID: 27535327 DOI: 10.1093/fampra/cmw077] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Early detection and intervention for chronic obstructive pulmonary disease (COPD) could potentially slow disease progress and minimize harm. OBJECTIVES To assess the effectiveness of early intervention by a practice nurse-GP team on quality of life (QoL) and process of care in patients with newly diagnosed COPD, compared with usual care. Nurses and GPs in intervention practices were educated to develop and implement disease management plans for COPD. METHODS A 12-month, multicentre, pragmatic randomized controlled trial with blinded outcome assessment was conducted. Participants were current and former smokers aged 40 to 85 years newly identified as having COPD on post-bronchodilator spirometry. The primary outcome was health-related QoL, assessed with the St George's Respiratory Questionnaire (SGRQ). Secondary outcome measures were other QoL measures, lung function, disease knowledge, smoking and immunization status, inhaler technique and health service use. RESULTS Of the 10 234 patients from 36 practices in Sydney invited to a case-finding appointment, 1641 (16%) attended and 287 (18%) were diagnosed with COPD. Nineteen practices (144 patients) were randomized to the intervention group and 17 practices (110 patients) to the control group. Only 15.3% (n = 22) patients in the intervention group saw the nurse for COPD care following case finding. There was no between-group difference in SGRQ score at follow-up (mean difference -0.21; P = 0.86). Influenza vaccination was higher in the intervention group (OR 2.31: P = 0.035), but there were no other significant between-group differences in outcomes. CONCLUSION Intervention uptake was low and had no additional beneficial effect, over usual care, on participants' health-related QoL.
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Affiliation(s)
- Nicholas A Zwar
- School of Public Health and Community Medicine, UNSW Australia, UNSW Sydney, Australia,
| | - Jeremy M Bunker
- School of Public Health and Community Medicine, UNSW Australia, UNSW Sydney, Australia
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Glebe, Australia
| | - Sarah M Dennis
- Faculty of Health Sciences, University of Sydney, Lidcombe, Australia.,Centre for Primary Health Care and Equity, UNSW Australia, UNSW Sydney, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Darlinghurst, Australia
| | | | - Alan J Crockett
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Iqbal Hasan
- Centre for Primary Health Care and Equity, UNSW Australia, UNSW Sydney, Australia
| | - Oshana Hermiz
- Centre for Primary Health Care and Equity, UNSW Australia, UNSW Sydney, Australia
| | - Sanjyot Vagholkar
- School of Public Health and Community Medicine, UNSW Australia, UNSW Sydney, Australia
| | - Wei Xuan
- Ingham Institute for Applied Medical Research, Liverpool, Australia and
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney, Glebe, Australia.,South Western Sydney Clinical School, UNSW Australia, Liverpool, Australia
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31
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Jonkman NH, Westland H, Trappenburg JC, Groenwold RH, Bischoff EW, Bourbeau J, Bucknall CE, Coultas D, Effing TW, Epton MJ, Gallefoss F, Garcia-Aymerich J, Lloyd SM, Monninkhof EM, Nguyen HQ, van der Palen J, Rice KL, Sedeno M, Taylor SJ, Troosters T, Zwar NA, Hoes AW, Schuurmans MJ. Do self-management interventions in COPD patients work and which patients benefit most? An individual patient data meta-analysis. Int J Chron Obstruct Pulmon Dis 2016; 11:2063-74. [PMID: 27621612 PMCID: PMC5012618 DOI: 10.2147/copd.s107884] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Self-management interventions are considered effective in patients with COPD, but trials have shown inconsistent results and it is unknown which patients benefit most. This study aimed to summarize the evidence on effectiveness of self-management interventions and identify subgroups of COPD patients who benefit most. Methods Randomized trials of self-management interventions between 1985 and 2013 were identified through a systematic literature search. Individual patient data of selected studies were requested from principal investigators and analyzed in an individual patient data meta-analysis using generalized mixed effects models. Results Fourteen trials representing 3,282 patients were included. Self-management interventions improved health-related quality of life at 12 months (standardized mean difference 0.08, 95% confidence interval [CI] 0.00–0.16) and time to first respiratory-related hospitalization (hazard ratio 0.79, 95% CI 0.66–0.94) and all-cause hospitalization (hazard ratio 0.80, 95% CI 0.69–0.90), but had no effect on mortality. Prespecified subgroup analyses showed that interventions were more effective in males (6-month COPD-related hospitalization: interaction P=0.006), patients with severe lung function (6-month all-cause hospitalization: interaction P=0.016), moderate self-efficacy (12-month COPD-related hospitalization: interaction P=0.036), and high body mass index (6-month COPD-related hospitalization: interaction P=0.028 and 6-month mortality: interaction P=0.026). In none of these subgroups, a consistent effect was shown on all relevant outcomes. Conclusion Self-management interventions exert positive effects in patients with COPD on respiratory-related and all-cause hospitalizations and modest effects on 12-month health-related quality of life, supporting the implementation of self-management strategies in clinical practice. Benefits seem similar across the subgroups studied and limiting self-management interventions to specific patient subgroups cannot be recommended.
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Affiliation(s)
- Nini H Jonkman
- Department of Rehabilitation, Nursing Science and Sports
| | | | | | - Rolf Hh Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
| | - Erik Wma Bischoff
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University Health Center, McGill University, Montreal, QC, Canada
| | | | - David Coultas
- Veterans Administration Portland Health Care System and Oregon Health & Science University, Portland, OR, USA
| | - Tanja W Effing
- Department of Respiratory Medicine, Repatriation General Hospital, Adelaide, SA, Australia
| | - Michael J Epton
- Canterbury District Health Board, Respiratory Services, Christchurch Hospital, Christchurch, New Zealand
| | - Frode Gallefoss
- Department of Pulmonary Medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Judith Garcia-Aymerich
- Centre for Research in Environmental Epidemiology CREAL; Pompeu Fabra University; CIBER Epidemiología y Salud Pública CIBERESP, Barcelona, Spain
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Job van der Palen
- Department of Research Methodology, Measurement and Data Analysis, University of Twente; Department of Clinical Epidemiology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Kathryn L Rice
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Minneapolis Veterans Affairs Health Care Service and University of Minnesota, Minneapolis, MN, USA
| | - Maria Sedeno
- Respiratory Epidemiology and Clinical Research Unit, Department of Medicine, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Stephanie Jc Taylor
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Thierry Troosters
- Department of Rehabilitation Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, Australia
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
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32
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Jonkman NH, Westland H, Trappenburg JCA, Groenwold RHH, Bischoff EWMA, Bourbeau J, Bucknall CE, Coultas D, Effing TW, Epton M, Gallefoss F, Garcia-Aymerich J, Lloyd SM, Monninkhof EM, Nguyen HQ, van der Palen J, Rice KL, Sedeno M, Taylor SJC, Troosters T, Zwar NA, Hoes AW, Schuurmans MJ. Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis. Eur Respir J 2016. [PMID: 27126694 DOI: 10.1183/13993003.01860‐2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
It is unknown whether heterogeneity in effects of self-management interventions in patients with chronic obstructive pulmonary disease (COPD) can be explained by differences in programme characteristics. This study aimed to identify which characteristics of COPD self-management interventions are most effective.Systematic search in electronic databases identified randomised trials on self-management interventions conducted between 1985 and 2013. Individual patient data were requested for meta-analysis by generalised mixed effects models.14 randomised trials were included (67% of eligible), representing 3282 patients (75% of eligible). Univariable analyses showed favourable effects on some outcomes for more planned contacts and longer duration of interventions, interventions with peer contact, without log keeping, without problem solving, and without support allocation. After adjusting for other programme characteristics in multivariable analyses, only the effects of duration on all-cause hospitalisation remained. Each month increase in intervention duration reduced risk of all-cause hospitalisation (time to event hazard ratios 0.98, 95% CI 0.97-0.99; risk ratio (RR) after 6 months follow-up 0.96, 95% CI 0.92-0.99; RR after 12 months follow-up 0.98, 95% CI 0.96-1.00).Our results showed that longer duration of self-management interventions conferred a reduction in all-cause hospitalisations in COPD patients. Other characteristics are not consistently associated with differential effects of self-management interventions across clinically relevant outcomes.
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Affiliation(s)
- Nini H Jonkman
- Dept of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heleen Westland
- Dept of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap C A Trappenburg
- Dept of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erik W M A Bischoff
- Dept of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jean Bourbeau
- Respiratory Epidemiology and Clinical Research Unit, Dept of Medicine, McGill University Health Center, McGill University, Montreal, Canada
| | | | - David Coultas
- Veterans Administration Portland Health Care System and Oregon Health & Science University, Portland, OR, USA
| | - Tanja W Effing
- Dept of Respiratory Medicine, Repatriation General Hospital, Adelaide, Australia
| | - Michael Epton
- Canterbury District Health Board, Respiratory Services, Christchurch Hospital, Christchurch, New Zealand
| | - Frode Gallefoss
- Dept of Pulmonary Medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Judith Garcia-Aymerich
- Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain Universitat Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Evelyn M Monninkhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Huong Q Nguyen
- Dept of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Job van der Palen
- Dept of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands Department of Clinical Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Kathryn L Rice
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Minneapolis Veterans Affairs Health Care Service and University of Minnesota, Minneapolis, USA
| | - Maria Sedeno
- Respiratory Epidemiology and Clinical Research Unit, Dept of Medicine, McGill University Health Center, McGill University, Montreal, Canada
| | - Stephanie J C Taylor
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Thierry Troosters
- Dept of Rehabilitation Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, UNSW Australia, Sydney, Australia
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marieke J Schuurmans
- Dept of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
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Jonkman NH, Westland H, Trappenburg JC, Groenwold RH, Bischoff EW, Bourbeau J, Bucknall CE, Coultas D, Effing TW, Epton M, Gallefoss F, Garcia-Aymerich J, Lloyd SM, Monninkhof EM, Nguyen HQ, van der Palen J, Rice KL, Sedeno M, Taylor SJ, Troosters T, Zwar NA, Hoes AW, Schuurmans MJ. Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis. Eur Respir J 2016; 48:55-68. [DOI: 10.1183/13993003.01860-2015] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/16/2016] [Indexed: 11/05/2022]
Abstract
It is unknown whether heterogeneity in effects of self-management interventions in patients with chronic obstructive pulmonary disease (COPD) can be explained by differences in programme characteristics. This study aimed to identify which characteristics of COPD self-management interventions are most effective.Systematic search in electronic databases identified randomised trials on self-management interventions conducted between 1985 and 2013. Individual patient data were requested for meta-analysis by generalised mixed effects models.14 randomised trials were included (67% of eligible), representing 3282 patients (75% of eligible). Univariable analyses showed favourable effects on some outcomes for more planned contacts and longer duration of interventions, interventions with peer contact, without log keeping, without problem solving, and without support allocation. After adjusting for other programme characteristics in multivariable analyses, only the effects of duration on all-cause hospitalisation remained. Each month increase in intervention duration reduced risk of all-cause hospitalisation (time to event hazard ratios 0.98, 95% CI 0.97–0.99; risk ratio (RR) after 6 months follow-up 0.96, 95% CI 0.92–0.99; RR after 12 months follow-up 0.98, 95% CI 0.96–1.00).Our results showed that longer duration of self-management interventions conferred a reduction in all-cause hospitalisations in COPD patients. Other characteristics are not consistently associated with differential effects of self-management interventions across clinically relevant outcomes.
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Fatema K, Zwar NA, Milton AH, Rahman B, Awal ASMN, Ali L. Cardiovascular risk assessment among rural population: findings from a cohort study in a peripheral region of Bangladesh. Public Health 2016; 137:73-80. [PMID: 27036981 DOI: 10.1016/j.puhe.2016.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 01/20/2016] [Accepted: 02/15/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The incidences of non-communicable diseases including cardiovascular diseases (CVDs) is increasing in Bangladesh. The reasons for this increasing trend need to be explored. The aim of this study is to assess the risk of CVDs among a peripheral rural Bangladeshi population and to explore the sociodemographic, anthropometric and clinical variables associated with increased risk. STUDY DESIGN Cohort study. METHODS From a cohort of 190,471 individuals of all ages, originally included in a diabetic eye disease program initiated in 2008-2009, a purposive sub-cohort of 66,710 individuals, aged 31-74 years was recruited. During 2011-2012 these participants were assessed for CVDs using the WHO's risk assessment tool designed for primary care settings in low resource societies. Participant characteristics associated with higher risk were explored using univariable and multivariable regression analysis. RESULTS Out of all (95.5% participation rate) participants 1170 (1.84%) were found to be at high risk for CVD. The prevalence of hypertension (HTN), pre-HTN, obesity, underweight and self-reported DM were 8.9%, 15.2%, 9.6%, 7.8% and 0.5% respectively, among the study population. In multivariable regression analysis female sex, older age, temporary housing structure (i.e., tin shed), extremes of BMI (both underweight and obese) and central obesity were associated with higher risk for CVDs. CONCLUSIONS The prevalence of CVD risk factors and high CVD risk individuals in this cohort was found to be lower than previous studies. It may be the effects of urbanization are yet to reach this relatively traditional rural population. This study adds to the literature on use of the WHO risk assessment tool.
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Affiliation(s)
- K Fatema
- Department of Epidemiology, Bangladesh University of Health Sciences (BUHS), 125/1 Darus Salam, Mirpur, Dhaka 1216, Bangladesh; The School of Public Health and Community Medicine, Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia.
| | - N A Zwar
- The School of Public Health and Community Medicine, Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia.
| | - A H Milton
- Centre for Clinical Epidemiology and Biostatistics (CCEB), The School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW 2008, Australia.
| | - B Rahman
- The School of Public Health and Community Medicine, Faculty of Medicine, The University of New South Wales, Sydney, NSW 2052, Australia.
| | - A S M N Awal
- ORBIS International, Apartment No, B4 & C4, Plot #1, Road #137, Gulshan, Dhaka 1212, Bangladesh.
| | - L Ali
- Department of Biochemistry and Cell Biology, BUHS, 125/1 Darus Salam, Mirpur, Dhaka 1216, Bangladesh.
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Dennis S, Hetherington SA, Borodzicz JA, Hermiz O, Zwar NA. Challenges to establishing successful partnerships in community health promotion programs: local experiences from the national implementation of healthy eating activity and lifestyle (HEAL™) program. Health Promot J Austr 2015; 26:45-51. [PMID: 26149254 DOI: 10.1071/he14035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 01/06/2015] [Indexed: 11/23/2022] Open
Abstract
ISSUE ADDRESSED Community-based programs to address physical activity and diet are seen as a valuable strategy to reduce risk factors for chronic disease. Community partnerships are important for successful local implementation of these programs but little is published to describe the challenges of developing partnerships to implement health promotion programs. The aim of this study was to explore the experiences and opinions of key stakeholders on the development and maintenance of partnerships during their implementation of the HEAL™ program. METHOD Semi-structured interviews with key stakeholders involved in implementation of HEAL™ in four local government areas. The interviews were transcribed verbatim and analysed thematically. RESULTS Partnerships were vital to the success of the local implementation. Successful partnerships occurred where the program met the needs of the partnering organisation, or could be adapted to do so. Partnerships took time to develop and were often dependent on key people. Partnering with organisations that had a strong influence in the community could strengthen existing relationships and success. In remote areas partnerships took longer to develop because of fewer opportunities to meet face to face and workforce shortages and this has implications for program funding in these areas. CONCLUSION Partnerships are important for the successful implementation of community preventive health programs. They take time to develop, are dependent on the needs of the stakeholders and are facilitated by stable leadership. SO WHAT?: An understanding of the role of partnerships in the implementation of community health programs is important to inform several aspects of program delivery, including flexibility in funding arrangements to allow effective and mutually beneficial partnerships to develop before the implementation phase of the program. It is important that policy makers have an understanding of the time it takes for partnerships to develop and to take this into consideration when programs are funded and implemented in the community.
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Affiliation(s)
- Sarah Dennis
- Clinical and Rehabilitation Sciences, Faculty of Health Sciences, University of Sydney, 74 East Street, Lidcombe, NSW 2141, Australia
| | | | - Jerrad A Borodzicz
- South Western Sydney Medicare Local, Level 3, 1 Bolger Street, Campbelltown, NSW 2560, Australia
| | - Oshana Hermiz
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW 2052, Australia
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia
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Halcomb EJ, Furler JS, Hermiz OS, Blackberry ID, Smith JP, Richmond RL, Zwar NA. Process evaluation of a practice nurse-led smoking cessation trial in Australian general practice: views of general practitioners and practice nurses. Fam Pract 2015; 32:468-73. [PMID: 26024924 DOI: 10.1093/fampra/cmv041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Support in primary care can assist smokers to quit successfully, but there are barriers to general practitioners (GPs) providing this support routinely. Practice nurses (PNs) may be able to effectively take on this role. OBJECTIVES The aim of this study was to perform a process evaluation of a PN-led smoking cessation intervention being tested in a randomized controlled trial in Australian general practice. METHODS Process evaluation was conducted by means of semi-structured telephone interviews with GPs and PNs allocated in the intervention arm (Quit with PN) of the Quit in General Practice trial. Interviews focussed on nurse training, content and implementation of the intervention. RESULTS Twenty-two PNs and 15 GPs participated in the interviews. The Quit with PN intervention was viewed positively. Most PNs were satisfied with the training and the materials provided. Some challenges in managing patient data and follow-up were identified. CONCLUSION The Quit with PN intervention was acceptable to participating PNs and GPs. Issues to be addressed in the planning and wider implementation of future trials of nurse-led intervention in general practice include providing ongoing mentoring support, integration into practice management systems and strategies to promote greater collaboration in GPs and PN teams in general practice. The ongoing feasibility of the intervention was impacted by the funding model supporting PN employment and the competing demands on the PNs time.
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Affiliation(s)
| | - John S Furler
- Department of General Practice, University of Melbourne, Carlton, Victoria
| | - Oshana S Hermiz
- Centre for Primary Health Care and Equity, University of NSW, Sydney
| | - Irene D Blackberry
- Department of General Practice, University of Melbourne, Carlton, Victoria, John Richards Initiative, La Trobe University, Wodonga, Victoria
| | - Julie P Smith
- Regulatory Institutions Network, The Australian National University, Canberra, ACT and
| | - Robyn L Richmond
- School of Public Health and Community Medicine, UNSW Australia, Sydney, New South Wales
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, UNSW Australia, Sydney, New South Wales
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Zwar NA, Richmond RL, Halcomb EJ, Furler JS, Smith JP, Hermiz O, Blackberry ID, Jayasinghe UW, Borland R. Quit in general practice: a cluster randomized trial of enhanced in-practice support for smoking cessation. Fam Pract 2015; 32:173-80. [PMID: 25670206 DOI: 10.1093/fampra/cmu089] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the uptake and effectiveness of tailored smoking cessation support, provided primarily by the practice nurse (PN), and compare this to other forms of cessation support. METHODS Three arm cluster randomized controlled trial conducted in 101 general practices in Sydney and Melbourne involving 2390 smokers. The Quit with PN intervention was compared to Quitline referral and a usual care control group. Smoking cessation pharmacotherapy was recommended to all groups. Outcomes were assessed by self-report at 3- and 12-month follow-up. Uptake of the interventions is also reported. RESULTS The three groups were similar at baseline. Follow-up at 12 months was 82%. The sustained and point prevalence abstinence rates, respectively, at 3 months by group were: PN intervention 13.1% and 16.3%; Quitline referral 10.8% and 14.2%; Usual GP care 11.4% and 15.0%. At 12 months, the rates were: PN intervention 5.4% and 17.1%; Quitline referral 4.4% and 18.8%; Usual GP care 2.9% and 16.4%. Only 43% of patients in the PN intervention group attended to see the nurse. Multilevel regression analysis showed no effect of the intervention overall, but patients who received partial or complete PN support were more likely to report sustained abstinence [partial support odds ratio (OR) 2.27; complete support OR 5.34]. CONCLUSION The results show no difference by group on intention to treat analysis. Those patients who received more intensive PN intervention were more likely to quit. This may have been related to patient motivation or an effect of PN led cessation support.
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Affiliation(s)
- Nicholas A Zwar
- School of Public Health and Community Medicine, UNSW Australia, Kensington, New South Wales, Australia,
| | - Robyn L Richmond
- School of Public Health and Community Medicine, UNSW Australia, Kensington, New South Wales, Australia
| | - Elizabeth J Halcomb
- School of Nursing, Midwifery & Indigenous Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - John S Furler
- General Practice and Primary Health Care Academic Centre, University of Melbourne, Parkville, Victoria, Australia
| | - Julie P Smith
- Australian Centre for Economic Research on Health, Australian National University, Canberra, Australia
| | - Oshana Hermiz
- Centre for Primary Health Care and Equity, UNSW Australia, Sydney, Australia and
| | - Irene D Blackberry
- General Practice and Primary Health Care Academic Centre, University of Melbourne, Parkville, Victoria, Australia
| | - Upali W Jayasinghe
- Centre for Primary Health Care and Equity, UNSW Australia, Sydney, Australia and
| | - Ron Borland
- Cancer Council Victoria, Melbourne, Victoria, Australia
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Stanley AJ, Hasan I, Crockett AJ, van Schayck OCP, Zwar NA. Validation of the COPD Diagnostic Questionnaire in an Australian general practice cohort: a cross-sectional study. Prim Care Respir J 2014; 23:92-7. [PMID: 24570082 PMCID: PMC6442288 DOI: 10.4104/pcrj.2014.00015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The gold standard for the diagnosis of chronic obstructive pulmonary disease (COPD) is spirometry, but there are barriers to its use in primary care. AIMS To externally validate the COPD Diagnostic Questionnaire (CDQ) as a diagnostic tool in patients at increased risk in Australian general practice and to compare its performance with other CDQ validation studies. METHODS Patients were recruited from 36 general practices in Sydney, Australia. Former or current smokers aged 40-85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse. The CDQ was collected and pre- and postbronchodilator spirometry was performed. Cases for whom complete CDQ data were present and the spirometry met quality standards were analysed. RESULTS Of 1,631 patients who attended case-finding recruitment, 1,054 (65%) could be analysed. Spirometry showed 13% had COPD. The ability of the CDQ to discriminate between patients with and without COPD was fair, represented by the area under the receiver operating characteristic curve of 0.713. With a CDQ cut-off point value of 16.5 the sensitivity was 80% and specificity 47% and, at a cut-off point value of 19.5, the sensitivity was 63% and specificity 70%. CONCLUSIONS The CDQ did not discriminate between patients with and without COPD accurately enough to use as a diagnostic tool in patients at increased risk of COPD in Australian general practice. Further research is needed on the value of the CDQ as a tool for selecting patients for spirometry.
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Affiliation(s)
- Anthony J Stanley
- School of Public Health and Community Medicine, University of New South Wales, Kensington, NSW, Australia
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Stanley AJ, Hasan I, Crockett AJ, van Schayck OCP, Zwar NA. COPD Diagnostic Questionnaire (CDQ) for selecting at-risk patients for spirometry: a cross-sectional study in Australian general practice. NPJ Prim Care Respir Med 2014; 24:14024. [PMID: 25010522 PMCID: PMC4373382 DOI: 10.1038/npjpcrm.2014.24] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 03/31/2014] [Accepted: 05/06/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Using the COPD Diagnostic Questionnaire (CDQ) as a selection tool for spirometry could potentially improve the efficiency and accuracy of chronic obstructive pulmonary disease (COPD) diagnosis in at-risk patients. AIM To identify an optimal single cut point for the CDQ that divides primary care patients into low or high likelihood of COPD, with the latter group undergoing spirometry. METHODS Former or current smokers aged 40-85 years with no prior COPD diagnosis were invited to a case-finding appointment with the practice nurse at various general practices in Sydney, Australia. The CDQ was collected and pre- and post-bronchodilator spirometry was performed. Cases with complete CDQ data and spirometry meeting quality standards were analysed (1,054 out of 1,631 patients). CDQ cut points were selected from a receiver operating characteristic (ROC) curve. RESULTS The area under the ROC curve was 0.713. A cut point of 19.5 had the optimal combination of sensitivity (63%) and specificity (70%) with two-thirds below this cut point. A cut point of 14.5 corresponded to a sensitivity of 91%, specificity of 35% and negative predictive value of 96%, and 31% of patients below this cut point. CONCLUSIONS The CDQ can be used to select patients at risk of COPD for spirometry using one cut point. We consider two possible cut points. The 19.5 cut point excludes a higher proportion of patients from undergoing spirometry with the trade-off of more false negatives. The 14.5 cut point has a high sensitivity and negative predictive value, includes more potential COPD cases but has a higher rate of false positives.
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Affiliation(s)
- Anthony J Stanley
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
| | - Iqbal Hasan
- Centre for Health Equity Training Research and Evaluation (CHETRE), Ingham Institute, Liverpool BC, New South Wales, Australia
| | - Alan J Crockett
- 1] School of Health, University of South Australia, Adelaide, South Australia, Australia [2] Discipline of General Practice, School of Population Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Onno C P van Schayck
- Department of General Practice, CAHPRI School for Public Health and Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia
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Harris MF, Zwar NA. Reflections on the history of general practice in Australia. Med J Aust 2014; 201:S37-40. [DOI: 10.5694/mja14.00141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/15/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW
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Zwar NA, Mendelsohn CP, Richmond RL. Tobacco smoking: options for helping smokers to quit. Aust Fam Physician 2014; 43:348-354. [PMID: 24897982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Although great progress has been made on tobacco control, smoking remains one of the most important causes of preventable disease and death in the Australian population. The general practice team has much to offer in helping smokers to quit. OBJECTIVE This article provides practical advice on structuring smoking cessation support in primary care using the 5As (Ask, Assess, Advise, Assist and Arrange follow-up) framework. Up-to-date information on pharmacotherapy and issues for special groups are also covered. DISCUSSION The chances of successful quitting are maximised if the patient receives behavioural support combined with drug treatment, if nicotine-dependent. Special groups needing support include Aboriginal and Torres Strait Islander peoples, people with mental illness and pregnant women.
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Affiliation(s)
- Nicholas A Zwar
- MBBS, MPH, PhD, FRACGP, is Professor of General Practice, School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales
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Affiliation(s)
- Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney 2052, Australia
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Rhee JJ, Zwar NA, Kemp LA. Why Are Advance Care Planning Decisions Not Implemented? Insights from Interviews with Australian General Practitioners. J Palliat Med 2013; 16:1197-204. [DOI: 10.1089/jpm.2013.0156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joel J. Rhee
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Nicholas A. Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Lynn A. Kemp
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
- Centre for Health Equity Training Research and Evaluation (CHETRE), University of New South Wales, Sydney, Australia
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Abstract
BACKGROUND Advance care planning (ACP) has been gaining prominence for its perceived benefits for patients in enhancing patient autonomy and ensuring high-quality end-of-life-care. Moreover, it has been postulated that ACP has positive effects on families and health professionals and their relationship with the patient. However, there is a paucity of studies examining the views of GPs on this issue. OBJECTIVE To explore GP views on the impact that ACP has on interpersonal relationships among those involved in the patient's care. METHOD Semi-structured, open-ended interviews of a purposive sample of 17 GPs. Interview transcripts were analysed using constructionist grounded theory methodology with QSR NVivo 9 software. RESULTS ACP was seen as having both positive and negative impacts on interpersonal relationships. It was thought to enhance family relationships, help resolve conflicts between families and health professionals and improve trust and understanding between patients and health professionals. Negatively, it could take the family's attention away from patient care. The link between ACP and interpersonal relationships was perceived to be bidirectional-the nature of interpersonal relationship that patients have with their families and health professionals has a profound impact on what form of ACP is likely to be useful. CONCLUSION Our study highlights the importance that GPs place on the link between ACP and the patient's interpersonal context. This has implications on how ACP is conducted in primary care settings that are considerably different from other care settings in their emphasis on continuity of care and long-term nature of relationships.
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Affiliation(s)
- Joel J Rhee
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.
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Cameron HE, Boreland FT, Morris JR, Lyle DM, Perkins DA, Magin PJ, Marshall MJ, Zwar NA. New South Wales and Australian Capital Territory Researcher Development Program 2005–07: modest investment, considerable outcomes. Aust J Prim Health 2013; 19:59-67. [DOI: 10.1071/py11155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 12/28/2011] [Indexed: 11/23/2022]
Abstract
This evaluation of the Researcher Development Program (RDP) in NSW and ACT aimed to determine whether the RDP was effective in assisting novice researchers to undertake primary health care research. In mid-2008, 47 participants of the NSW and ACT RDP during 2005–07 were invited to participate in a postal survey. The survey included questions regarding previous research training and experience, outcomes during and after participation in the program, and organisational aspects of the program. Follow-up interviews were conducted with selected participants. Interview questions covered time in the program, supervision, organisational support and placement outcomes. Thirty-seven participants responded to the survey and 23 (62%) participants took part in the semi-structured interviews. Seventy-eight per cent of survey respondents felt that the RDP helped them move from novice to a more experienced researcher with effective supervision identified by participants as a key element in determining the success of the program. Many felt that time allocation was inadequate and 20% thought their capacity to maintain their workload was adversely affected by participating. Outcomes were considerable given the modest nature of the program. Notable outcomes were that most participants published their research and presented their research at a conference. Furthermore, one-fifth of survey respondents had enrolled in higher degrees. Several interviewees reported that their research led to changes in practice. Most respondents found the RDP valuable and considered that undertaking the program increased their research knowledge.
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Harris MF, Davies PGP, Fanaian M, Zwar NA, Liaw ST. Access to same day, next day and after-hours appointments: the views of Australian general practitioners. AUST HEALTH REV 2012; 36:325-30. [PMID: 22935126 DOI: 10.1071/ah11080] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 02/12/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate factors associated with the availability of same or next day appointments and after-hours access reported by Australian general practitioners (GPs). METHODS Secondary analysis of a survey of primary care practitioners conducted by the Commonwealth Fund in 2009 in 11 countries. Analysis of factors likely to be associated with reported availability of same or next day appointments and after-hours access. FINDINGS Of 1016 Australian GPs, 78.8% reported that most patients in their practice had access to an appointment on the same or next day and 50% that their practice had arrangements for after-hours access. Access to same or next day care was better in practices where practitioners reported larger numbers of patients seen per GP per week and reviewed their performance against annual targets, but worse in rural areas and practices routinely reviewing outcomes data. Arrangements for after-hours care were more common among GPs who were planning to retire in the next 5 years; worked in practices with high electronic functioning information systems; and received and reviewed clinical outcome data and incentives for performance. CONCLUSIONS Improving after-hours access requires a comprehensive approach which includes incentives, improvements to information management and organised systems of care with review of data on clinical outcomes.
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Affiliation(s)
- Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW 2052, Australia.
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Zwar NA, Hermiz O, Comino E, Middleton S, Vagholkar S, Xuan W, Wilson SF, Marks GB. Care of patients with a diagnosis of chronic obstructive pulmonary disease: a cluster randomised controlled trial. Med J Aust 2012; 197:394-8. [DOI: 10.5694/mja12.10813] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Sandy Middleton
- Centre for Clinical Outcomes Research, Australian Catholic University, Sydney, NSW
| | | | - Wei Xuan
- Woolcock Institute of Medical Research, Sydney, NSW
| | - Stephen F Wilson
- Department of Rehabilitation Medicine, Royal North Shore Hospital, Sydney, NSW
| | - Guy B Marks
- Woolcock Institute of Medical Research, Sydney, NSW
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Reddel HK, Dennis SM, Middleton S, Van Schayck CP, Crockett AJ, Hasan I, Hermiz O, Vagholkar S, Marks GB, Zwar NA. A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams: Study Protocol. Implement Sci 2012; 7:83. [PMID: 22958678 PMCID: PMC3457839 DOI: 10.1186/1748-5908-7-83] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 08/29/2012] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care. DESIGN A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD.The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities.The primary outcome measure is health-related quality of life, assessed with the St George's Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients' randomization groups. DISCUSSION This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care. TRIAL REGISTRATION ACTRN12610000592044\
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Affiliation(s)
- Helen K Reddel
- Woolcock Institute of Medical Institute, University of Sydney, Sydney, NSW, Australia
| | - Sarah M Dennis
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Sandy Middleton
- National Centre for Clinical Outcomes Research, Australia, Australian Catholic University, Sydney, NSW, Australia
| | - CP Van Schayck
- Research School Caphri, Maastricht University, Maastricht, The Netherlands
| | - Alan J Crockett
- Discipline of General Practice, School of Population Health And Clinical Practice, The University of Adelaide, Adelaide, 5005, South Australia
| | - Iqbal Hasan
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Oshana Hermiz
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Sanjyot Vagholkar
- General Practice Unit, Fairfield Hospital, South Western Sydney Local Health District/School of Public Health & Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney and Department of Respiratory Medicine, Liverpool Hospital, Liverpool, NSW, 2170, Australia
| | - Nicholas A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
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Zwar NA, Torda A. [Diarrhea diagnosis in a traveler returning from India]. Praxis (Bern 1994) 2012; 101:259-263. [PMID: 22337516 DOI: 10.1024/1661-8157/a000874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- N A Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australien.
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Rhee JJ, Zwar NA, Kemp LA. Uptake and implementation of Advance Care Planning in Australia: findings of key informant interviews. AUST HEALTH REV 2012; 36:98-104. [PMID: 22513028 DOI: 10.1071/ah11019] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 04/27/2011] [Indexed: 11/23/2022]
Abstract
Objective. Advance Care Planning (ACP) has an important role in enhancing patient autonomy and guiding end-of-life care. However, there is low uptake of ACP and evidence that advance care plans are often not implemented. We explored these issues in interviews with expert clinicians and representatives of key stakeholder organisations with interest in end-of-life care. Method. Qualitative descriptive study of semi-structured telephone interviews with 23 participants. Results. Participants thought that the low uptake of ACP in Australia is a result of inadequate awareness, societal reluctance to discuss end-of-life issues, and lack of health professionals’ involvement in ACP. Problems in implementation of advance care plans were thought to be a result of problems in accessing ACP documents; interpreting written documents; making binding decisions for future unpredictable situations; and paternalistic attitudes of health professionals and families. Participants had different perspectives on how advance care plans should be implemented, with some believing in strict implementation, whereas others believed in a more flexible approach. Implications. Low uptake and poor implementation of advance care plans may be addressed by (1) increasing community awareness; (2) encouraging health professional involvement; and (3) system-wide implementation of multi-faceted interventions. A patient-centred approach to ACP is required to resolve the differences in views on how advance care plans should be implemented. What is known about the topic? Advance Care Planning (ACP) has been gaining prominence in Australia for its role in enhancing a patient’s autonomy and as an important component of good end-of-life care. Evidence from overseas and a limited number of Australian studies have identified several problems with ACP. First, the uptake of ACP seems to be low. Second, even when ACP process takes place, the resultant plans are often not implemented and make little effect on delivery of end-of-life care. What does this paper add? This paper confirms that the uptake of ACP is limited in Australia and is a result of inadequate awareness, societal reluctance to discuss end-of-life issues, and lack of health professionals’ involvement in ACP. Problems in implementation of advance care plans may be because of problems in: accessing ACP documents, interpreting written documents, making binding decisions for future unpredictable situations, and paternalistic attitudes of health professionals and families. This paper also shows that there are different perspectives in how advance care plans should be implemented, with some believing in strict implementation, whereas others believed in a more flexible approach. What are the implications for practitioners? This paper outlines several ways in which problems in the uptake and implementation of advance care plans may be addressed. This involves (1) increasing community awareness; (2) encouraging health professional involvement in ACP; and (3) system-wide implementation of multi-faceted interventions in ACP. Our findings also suggest that there needs to be a shift from a one-size-fits-all approach to implementing advance care plans to a more flexible patient-centred approach. This approach could ensure that a patient’s autonomy and right to self-determination are adequately protected, while also catering to the needs of those requiring more flexible approaches to end-of-life decision-making.
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Affiliation(s)
- Joel J Rhee
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia.
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