Examining the use of cannabidiol and delta-9-tetrahydrocannabinol-based medicine among individuals diagnosed with dementia living within residential aged care facilities: Results of a double-blind randomised crossover trial

OBJECTIVE

Dementia affects individuals older than 65 years. Currently, residential aged care facilities (RACF) use psychotropic medications to manage behavioural and neuropsychiatric symptoms of dementia (BPSD), which are recommended for short-term use and have substantial side effects, including increased mortality. Cannabinoid-based medicines (CBM) have some benefits that inhibit BPSD and cause minimal adverse effects (AEs), yet limited research has been considered with this population. The study aimed to determine a tolerable CBM dose (3:2 delta-9-tetrahydrocannabinol:cannabidiol), and assessed its effect on BPSD, quality of life (QoL) and perceived pain.

METHODS

An 18-week randomised, double-blinded, crossover trial was conducted. Four surveys, collected on seven occasions, were used to measure changes in BPSD, QoL and pain. Qualitative data helped to understand attitudes towards CBM. General linear mixed models were used in the analysis, and the qualitative data were synthesised.

RESULTS

Twenty-one participants (77% female participants, mean age 85) took part in the trial. No significant differences were seen between the placebo and CBM for behaviour, QOL or pain, except a decrease in agitation at the end of treatment in favour of CBM. The qualitative findings suggested improved relaxation and sleep among some individuals. Post hoc estimates on the data collected suggested that 50 cases would draw stronger conclusions on the Neuropsychiatric Inventory.

CONCLUSIONS

The study design was robust, rigorous and informed by RACF. The medication appeared safe, with minimal AEs experienced with CBM. Further studies incorporating larger samples when considering CBM would allow researchers to investigate the sensitivity of detecting BPSD changes within the complexity of the disease and concomitant with medications.

Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial

BACKGROUND

Low back pain is the leading cause of years lived with disability globally, but most interventions have only short-lasting, small to moderate effects. Cognitive functional therapy (CFT) is an individualised approach that targets unhelpful pain-related cognitions, emotions, and behaviours that contribute to pain and disability. Movement sensor biofeedback might enhance treatment effects. We aimed to compare the effectiveness and economic efficiency of CFT, delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling low back pain.

METHODS

RESTORE was a randomised, controlled, three-arm, parallel group, phase 3 trial, done in 20 primary care physiotherapy clinics in Australia. We recruited adults (aged ≥18 years) with low back pain lasting more than 3 months with at least moderate pain-related physical activity limitation. Exclusion criteria were serious spinal pathology (eg, fracture, infection, or cancer), any medical condition that prevented being physically active, being pregnant or having given birth within the previous 3 months, inadequate English literacy for the study's questionnaires and instructions, a skin allergy to hypoallergenic tape adhesives, surgery scheduled within 3 months, or an unwillingness to travel to trial sites. Participants were randomly assigned (1:1:1) via a centralised adaptive schedule to usual care, CFT only, or CFT plus biofeedback. The primary clinical outcome was activity limitation at 13 weeks, self-reported by participants using the 24-point Roland Morris Disability Questionnaire. The primary economic outcome was quality-adjusted life-years (QALYs). Participants in both interventions received up to seven treatment sessions over 12 weeks plus a booster session at 26 weeks. Physiotherapists and patients were not masked. This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12618001396213.

FINDINGS

Between Oct 23, 2018 and Aug 3, 2020, we assessed 1011 patients for eligibility. After excluding 519 (51·3%) ineligible patients, we randomly assigned 492 (48·7%) participants; 164 (33%) to CFT only, 163 (33%) to CFT plus biofeedback, and 165 (34%) to usual care. Both interventions were more effective than usual care (CFT only mean difference -4·6 [95% CI -5·9 to -3·4] and CFT plus biofeedback mean difference -4·6 [-5·8 to -3·3]) for activity limitation at 13 weeks (primary endpoint). Effect sizes were similar at 52 weeks. Both interventions were also more effective than usual care for QALYs, and much less costly in terms of societal costs (direct and indirect costs and productivity losses; -AU$5276 [-10 529 to -24) and -8211 (-12 923 to -3500).

INTERPRETATION

CFT can produce large and sustained improvements for people with chronic disabling low back pain at considerably lower societal cost than that of usual care.

FUNDING

Australian National Health and Medical Research Council and Curtin University.

Improving the Efficiency of Geographic Target Regions for Healthcare Interventions

Appropriate prioritisation of geographic target regions (TRs) for healthcare interventions is critical to ensure the efficient distribution of finite healthcare resources. In delineating TRs, both 'targeting efficiency', i.e., the return on intervention investment, and logistical factors, e.g., the number of TRs, are important. However, existing approaches to delineate TRs disproportionately prioritise targeting efficiency. To address this, we explored the utility of a method found within conservation planning: the software Marxan and an extension, MinPatch ('Marxan + MinPatch'), with comparison to a new method we introduce: the Spatial Targeting Algorithm (STA). Using both simulated and real-world data, we demonstrate superior performance of the STA over Marxan + MinPatch, both with respect to targeting efficiency and with respect to adequate consideration of logistical factors. For example, by design, and unlike Marxan + MinPatch, the STA allows for user-specification of a desired number of TRs. More broadly, we find that, while Marxan + MinPatch does consider logistical factors, it also suffers from several limitations, including, but not limited to, the requirement to apply two separate software tools, which is burdensome. Given these results, we suggest that the STA could reasonably be applied to help prevent inefficiencies arising due to targeting of interventions using currently available approaches.

The effect of Vitamin-K1 and Colchicine on Vascular Calcification Activity in subjects with Diabetes Mellitus (ViKCoVaC): A double-blind 2x2 factorial randomized controlled trial

BACKGROUND

There is currently no treatment for attenuating progression of arterial calcification. 18F-sodium fluoride positron emission tomography (18F-NaF PET) locates regions of calcification activity. We tested whether vitamin-K1 or colchicine affected arterial calcification activity.

METHODS

154 patients with diabetes mellitus and coronary calcification, as detected using computed tomography (CT), were randomized to one of four treatment groups (placebo/placebo, vitamin-K1 [10 mg/day]/placebo, colchicine [0.5 mg/day]/placebo, vitamin-K1 [10 mg/day]/ colchicine [0.5 mg/day]) in a double-blind, placebo-controlled 2x2 factorial trial of three months duration. Change in coronary calcification activity was estimated as a change in coronary maximum tissue-to-background ratio (TBRmax) on 18F-NaF PET.

RESULTS

149 subjects completed follow-up (vitamin-K1: placebo = 73:76 and colchicine: placebo = 73:76). Neither vitamin-K1 nor colchicine had a statistically significant effect on the coronary TBRmax compared with placebo (mean difference for treatment groups 0·00 ± 0·16 and 0·01 ± 0·17, respectively, p > 0.05). There were no serious adverse effects reported with colchicine or vitamin-K1.

CONCLUSIONS

In patients with type 2 diabetes, neither vitamin-K1 nor colchicine significantly decreases coronary calcification activity, as estimated by 18F-NaF PET, over a period of 3 months.

CLINICAL TRIAL REGISTRATION

ACTRN12616000024448.

Impact of the modifiable areal unit problem in assessing determinants of emergency department demand

OBJECTIVE

To examine the impact of the modifiable areal unit problem (MAUP) in an investigation of factors associated with ED demand in Perth, Western Australia, in 2016. Furthermore, to advocate a means of avoiding this impact.

METHODS

ED presentations were classified as: urgent medical, non-urgent medical, urgent trauma or non-urgent trauma. In each group, sex-stratified, age-adjusted multivariate associations with socio-economic status and distance to the nearest ED and general practitioner (GP) were estimated. Modelling was undertaken using different sets of spatial units: Australian Bureau of Statistics (ABS) Statistical Areas Level 1 (SA1s) and numerous aggregate-level zonations of SA1s (ABS SA2s and others).

RESULTS

Estimates obtained using the different units often varied widely: for seven (30%) of 24 strata defined by combinations of sex, ED type and covariate, the smallest and largest effect sizes differed in terms of direction; further, for 11 (65%) of the remaining 17 strata, the largest effect size was at least twice as high as the smallest. This demonstrates the MAUP's impact and that analyses based on a single set of spatial units are unreliable. To resolve the observed variation, we highlight the SA1-level estimates.

CONCLUSIONS

When formulating interventions targeting reduced ED utilisation, policy planners should be guided by evidence based on analysis of appropriate spatial units. This ideal is undermined by the widespread lack of acknowledgement of the MAUP in studies examining drivers of ED demand using spatially aggregated data. To avoid the MAUP, only estimates obtained through examining a minimal geographic unit should be relied upon.

Overcoming inefficiencies arising due to the impact of the modifiable areal unit problem on single-aggregation disease maps

BACKGROUND

In disease mapping, fine-resolution spatial health data are routinely aggregated for various reasons, for example to protect privacy. Usually, such aggregation occurs only once, resulting in 'single-aggregation disease maps' whose representation of the underlying data depends on the chosen set of aggregation units. This dependence is described by the modifiable areal unit problem (MAUP). Despite an extensive literature, in practice, the MAUP is rarely acknowledged, including in disease mapping. Further, despite single-aggregation disease maps being widely relied upon to guide distribution of healthcare resources, potential inefficiencies arising due to the impact of the MAUP on such maps have not previously been investigated.

RESULTS

We introduce the overlay aggregation method (OAM) for disease mapping. This method avoids dependence on any single set of aggregate-level mapping units through incorporating information from many different sets. We characterise OAM as a novel smoothing technique and show how its use results in potentially dramatic improvements in resource allocation efficiency over single-aggregation maps. We demonstrate these findings in a simulation context and through applying OAM to a real-world dataset: ischaemic stroke hospital admissions in Perth, Western Australia, in 2016.

CONCLUSIONS

The ongoing, widespread lack of acknowledgement of the MAUP in disease mapping suggests that unawareness of its impact is extensive or that impact is underestimated. Routine implementation of OAM can help avoid resource allocation inefficiencies associated with this phenomenon. Our findings have immediate worldwide implications wherever single-aggregation disease maps are used to guide health policy planning and service delivery.

Use of cannabinoid-based medicine among older residential care recipients diagnosed with dementia: study protocol for a double-blind randomised crossover trial

BACKGROUND

Dementia is a neurological condition that affects the cognitive and functional ability of the brain and is the leading cause of disability among those aged 65 years and above. More effective ways to manage dementia symptoms are needed because current treatment options (antidepressants and antipsychotics) can be ineffective and are associated with substantial side effects, including increased rate of mortality. Cannabinoid-based medicine (CBM) has shown an ability to inhibit some symptoms associated with dementia, and the adverse effects are often minimal; yet, little research has explored the use of CBM among this population.

AIM

To monitor the safety of a purified dose of CBM oil (3:2 delta-9-tetrahydrocannabinol:cannabidiol) on behaviour symptoms, quality of life and discomfort caused by pain.

METHODS/DESIGN

We will carry out an 18-week, randomised, double-blind crossover trial that consists of a 2-week eligibility period, two 6-week treatment cycles, and two 2-week washout periods (between both cycles and after the second treatment cycle). We aim to recruit 50 participants with dementia who are living in residential aged-care facilities. The participants will be randomised into two groups and will receive a dose of either CBM oil or placebo for the first treatment cycle and the opposite medication for the second. Data will be collected using the Neuropsychiatric Inventory Questionnaire, the Cohen-Mansfield Agitation Inventory, the Quality of Life in Alzheimer's Disease questionnaire, and the Abbey Pain Scale on seven occasions. These will be completed by the participants, aged-care staff, and nominated next of kin or family members. The participants' heart rate and blood pressure will be monitored weekly, and their body composition and weight will be monitored fortnightly by a research nurse, to assess individual dose response and frailty. In addition, pre- and post-surveys will be administered to aged-care staff and family members to understand their perceptions of CBM and to inform proposed focus groups consisting of the aged-care staff and next of kin.

DISCUSSION

The study design has been informed by medical professionals and key stakeholders, including those working in the residential aged-care industry to ensure patient safety, collection of non-invasive measures, and methodological rigor and study feasibility.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12619000474156. Registered on 21 March 2019.

Overcoming the misrepresentation of disease burden associated with single aggregation choropleth maps through combining information from many aggregations

BackgroundAccurate disease mapping based on spatiotemporal data is an important aspect of public health surveillance, targeting interventions, and health service planning. This is achieved by public health surveillance organisations around the world through the construction of choropleth maps based on single spatiotemporal aggregations of finer resolution data. However, such maps are undermined by their dependence on the spatiotemporal units used. This dependence is described by the related modifiable areal and temporal unit problems (MAUP; MTUP), also known as change of support problems (COSPs). AimTo accurately map disease. MethodsUsing ischaemic stroke admissions and mental health-related ED presentations in metropolitan Perth between 2013 and 2016 as exemplars, we present a novel zonation overlay approach for disease mapping. This method involves aggregating fine resolution spatial data numerous times instead of just once, using the automated zonation construction software AZTool. Results Through implementing the zonation overlay method in combination with a rolling window of time, both the MAUP and the MTUP may be overcome in the context of disease mapping. Furthermore, the AZTool zonations act as a geographical encryption key, allowing fine resolution, precise maps to be constructed while protecting the privacy of individuals. ConclusionHealth surveillance organisations continue to produce single aggregation choropleth maps of disease, without acknowledging their limitations except in rare cases. Producing such maps and suggesting they should guide policy makers, while being aware of but not acknowledging the impact of COSPs, could be described as scientific malfeasance. However, assuming that most researchers producing such maps are not intending to mislead, we must conclude that COSPs are poorly understood and their impact underestimated. The zonation overlay method we describe can help alleviate the consequences of this continued practice.

RESTORE-Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain: study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading cause of disability globally and its costs exceed those of cancer and diabetes combined. Recent evidence suggests that individualised cognitive and movement rehabilitation combined with lifestyle advice (cognitive functional therapy (CFT)) may produce larger and more sustained effects than traditional approaches, and movement sensor biofeedback may enhance outcomes. Therefore, this three-arm randomised controlled trial (RCT) aims to compare the clinical effectiveness and economic efficiency of individualised CFT delivered with or without movement sensor biofeedback, with usual care for patients with chronic, disabling LBP.

METHODS AND ANALYSIS

Pragmatic, three-arm, randomised, parallel group, superiority RCT comparing usual care (n=164) with CFT (n=164) and CFT-plus-movement-sensor-biofeedback (n=164). Inclusion criteria include: adults with a current episode of LBP >3 months; sought primary care ≥6 weeks ago for this episode of LBP; average LBP intensity of ≥4 (0-10 scale); at least moderate pain-related interference with work or daily activities. The CFT-only and CFT-plus-movement-sensor-biofeedback participants will receive seven treatment sessions over 12 weeks plus a 'booster' session at 26 weeks. All participants will be assessed at baseline, 3, 6, 13, 26, 40 and 52 weeks. The primary outcome is pain-related physical activity limitation (Roland Morris Disability Questionnaire). Linear mixed models will be used to assess the effect of treatment on physical activity limitation across all time points, with the primary comparison being a formal test of adjusted mean differences between groups at 13 weeks. For the economic (cost-utility) analysis, the primary outcome of clinical effect will be quality-adjusted life years measured across the 12-month follow-up using the EuroQol EQ-5D-5L .

ETHICS AND DISSEMINATION

Approved by Curtin University Human Research Ethics Committee (HRE2018-0062, 6 Feb 2018). Study findings will be disseminated through publication in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618001396213).

Anxiety and alcohol in the working-age population are driving a rise in mental health-related emergency department presentations: 15 year trends in emergency department presentations in Western Australia

OBJECTIVE

To evaluate age, gender and disease-specific trends in ED for mental health presentations over 15 years.

METHODS

The study population consisted of residents of metropolitan Perth, Western Australia, presenting to Perth ED between 1 July 2002 and 30 June 2017. Population rates of mental health-related ED presentations per year were calculated.

RESULTS

Rates of mental health ED presentations are significantly increasing in the working-age population for those with stress and anxiety-related diagnoses, particularly in younger females, and also for alcohol-related presentations for those aged 10-49 years, particularly in males.

CONCLUSION

The present study demonstrates that increased rates of mental health-related ED presentations are driven by increased rates of presentation for stress and anxiety-related and alcohol-related presentations in both genders across the working-age population.

Hospital admissions and emergency department presentations for dental conditions indicate access to hospital, rather than poor access to dental health care in the community

High rates of dental-related potentially preventable hospitalisations are thought to reflect poor access to non-hospital dental services. The association between accessibility (geographic and financial) to non-hospital dentists and potentially preventable hospitalisations was examined in Western Australia. Areas with persistently high rates of dental-related potentially preventable hospitalisations and emergency department (ED) presentations were mapped. Statistical models examined factors associated with these events. Persistently high rates of dental-related potentially preventable hospitalisations were clustered in metropolitan areas that were socioeconomically advantaged and had more dentists per capita (RR 1.06, 95% CI 1.04-1.08) after adjusting for age, sex, socioeconomics, and Aboriginality. Persistently high rates of ED presentations were clustered in socioeconomically disadvantaged areas near metropolitan EDs and with fewer dentists per capita (RR 0.91, 0.88-0.94). A positive association between dental-related potentially preventable hospitalisations and poor (financial or geographic) access to dentists was not found. Rather, rates of such events were positively associated with socioeconomic advantage, plus greater access to hospitals and non-hospital dental services. Furthermore, ED presentations for dental conditions are inappropriate indicators of poor access to non-hospital dental services because of their relationship with hospital proximity. Health service planners and policymakers should pursue alternative indicators of dental service accessibility.

Reducing bias in multivariate analyses due to the modifiable areal unit problem

IntroductionThe Modifiable Areal Unit Problem (MAUP) arises from the aggregation of data organized by spatially defined boundaries. Aggregated values are influenced by the shape (zone effect) and scale of the aggregated units. Aggregations of the same data using different zones or scales can give different analytical results, none reliable. Objectives and ApproachUsing population-level administrative health data in Western Australia, the objectives were to: accurately measure the association between health service utilization and demographic, socio-economic, and service accessibility variables; and develop models to accurately forecast areas of high health service utilization into the future. Multiple zone designs and aggregation scales were used to examine the impact of MAUP in association studies. These zone designs and scales were then used in all-subset model selection processes, combined with repeated k-fold cross-validation, to generate forecast maps of areas having high future rates of health service utilization. ResultsThe impact of the MAUP and methods to reduce this bias in association studies will be presented, for both simple and complex model designs. Maps indicating gradients of predicted probabilities of high rate of health service demand in the future can be used to optimize the placement of services, through the use of catchment areas based on road-network travel distance and population distributions. Conclusion/ImplicationsThe impact of the MAUP on the analysis of spatially-aggregated data has been considered intractable. However, methods to reduce the impact of the MAUP can improve policy and planning decisions based on such studies.

Patterns of Medicare-funded primary health and specialist consultations in Aboriginal and non-Aboriginal Australians in the two years before hospitalisation for ischaemic heart disease

BACKGROUND

Ischaemic heart disease (IHD) remains the leading cause of morbidity and mortality for both Aboriginal and non-Aboriginal Australians. Patterns of primary and specialist care in patients leading up to the first hospitalisation for IHD potentially impact on prevention and subsequent outcomes. We investigated the differences in general practice (GP), specialist and emergency department (ED) consultations, and associated resource use in Aboriginal and non-Aboriginal people in the two years preceding hospitalisation for IHD.

METHODS

Linked-data were used to identify first IHD admissions for Western Australians aged 25-74 years in 2002-2007. Person-linked GP, specialist and ED consultations were obtained from the Medicare Benefits Schedule (MBS) and ED records to assess health care access and costs for the preceding 2 years.

RESULTS

Aboriginal people constituted 4.7% of 27,230 IHD patients, 3.5% of 1,348,238 MBS records, and 14% of 33,170 ED presentations. Aboriginal (vs. non-Aboriginal) people were younger (mean 50.2 vs 60.5 years), more commonly women (45.2% vs 28.4%), had more comorbidities [Charlson index≥1, 35.2% vs 26.3%], were more likely to have had GP visits (adjusted rate-ratio 1.07, 95% CI 1.02-1.12), long/prolonged (16.0% vs 11.9%) consults and non-vocationally registered GP consults (17.1% vs 3.2%), but less likely to received specialist consults (mean 1.0 vs 4.1). Mean number of urgent/semi-urgent ED presentations in the year preceding the IHD admission was higher in Aboriginal people (2.9 vs 1.9). Aboriginal people incurred 2.7% of total associated MBS expenditure (estimated at $59.7 million). Mean total cost per person was 43.3% lower in Aboriginal patients, with cost differentials being greatest in diabetic and chronic kidney disease patients.

CONCLUSIONS

Despite being over-represented in urgent/semi-urgent ED presentations and admissions for IHD, Aboriginal people were under-resourced compared with the rest of the population, particularly in terms of specialist care prior to first IHD hospitalisation. The findings underscore the need for better primary and specialist shared care delivery models particularly for Aboriginal people.

Reducing Bruzzi's Formula to Remove Instability in the Estimation of Population Attributable Fraction for Health Outcomes

The aim of this study was to reconcile 3 approaches to calculating population attributable fractions and attributable burden percentage: the approach of Bruzzi et al. (Am J Epidemiol. 1985;122(5):904-914.), the maximum-likelihood method of Greenland and Drescher (Biometrics. 1993;49(3):865-872.), and the multivariable method of Tanuseputro et al. (Popul Health Metr. 2015;13:5.). Using data from a statewide point prevalence survey (Western Australian Point Prevalence Survey, 2014) linked to an administrative database, we compared estimates of attributable burden percentage obtained using the contrasting methods in 6 logistic models of health outcomes from the survey, estimating 95% confidence intervals using nonparametric and weighted bootstrap approaches. Our results show that instability can arise from the fundamental algebraic construction of Bruzzi's formula, and that this instability may substantially influence the calculation of attributable burden percentage and associated confidence intervals. These observations were confirmed in a simulation study. The algebraic reduction of Bruzzi's formula to the 2 alternative methods resulted in markedly more stable estimates for population attributable fraction and attributable burden percentage in cross-sectional studies and cohort designs with fixed follow-up time. We advocate the widespread implementation of the maximum-likelihood approach and the multivariable method.

Detection and management of familial hypercholesterolaemia in primary care in Australia: protocol for a pragmatic cluster intervention study with pre-post intervention comparisons

INTRODUCTION

Familial hypercholesterolaemia (FH), an autosomal dominant disorder of lipid metabolism, results in accelerated onset of atherosclerosis if left untreated. Lifelong treatment with diet, lifestyle modifications and statins enable a normal lifespan for most patients. Early diagnosis is critical. This protocol trials a primary care-based model of care (MoC) to improve detection and management of FH.

METHODS AND ANALYSIS

Pragmatic cluster intervention study with pre-post intervention comparisons in Australian general practices. At study baseline, current FH detection practice is assessed. Medical records over 2 years are electronically scanned using a data extraction tool (TARB-Ex) to identify patients at increased risk. High-risk patients are clinically reviewed to provide definitive, phenotypic diagnosis using Dutch Lipid Clinic Network Criteria. Once an index family member with FH is identified, the primary care team undertake cascade testing of first-degree relatives to identify other patients with FH. Management guidance based on disease complexity is provided to the primary care team. Study follow-up to 12 months with TARB-Ex rerun to identify total number of new FH cases diagnosed over study period (via TARB-Ex, cascade testing and new cases presenting). At study conclusion, patient and clinical staff perceptions of enablers/barriers and suggested improvements to the approach will be examined. Resources at each stage will be traced to determine the economic implications of implementing the MoC and costed from health system perspective. Primary outcomes: increase in number of index cases clinically identified; reduction in low-density lipoprotein cholesterol of treated cases.

SECONDARY OUTCOMES

increase in the number of family cases detected/contacted; cost implications of the MoC.

ETHICS AND DISSEMINATION

Study approval by The University of Notre Dame Australia Human Research Ethics Committee Protocol ID: 0 16 067F. Registration: Australian New Zealand Clinical Trials Registry ID: 12616000630415. Information will be disseminated via research seminars, conference presentations, journal articles, media releases and community forums.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ID 12616000630415; Pre-results.

PEAC Events: identification of Predictable, Expensive, Avoidable, and Cardinal events within a learning health system

ABSTRACT ObjectivesThe objectives of this project are to identify patients that can be recruited into specific interventions and the optimisation of the delivery of such interventions, in order to improve access to health services, equity of service delivery, and patient outcomes.ApproachThe entire linked Western Australian Data Collections from 2002-2015 (including population-wide hospital admissions, emergency department presentations, cancer registry records, mental health care, maternity records, and mortality records) were examined. To identify patients at risk, a definition of a ‘PEAC’ event was developed. This acronym reflects the following criteria for such events. First, the event should ‘predictable’, i.e. either able to be easily predicted, or able to predict subsequent poor patient outcomes (for example, death). Second, the event should be ‘expensive’, i.e. be associated with significantly increased levels of individual healthcare utilisation and/or mortality. Third, the impact of the event should be ‘avoidable’, i.e. an evidence-based intervention should exist that may delay or completely avoid the event, or reduce its sequelae. Fourth, the event should be ‘cardinal’, which in this context indicates that the event should be clearly and unambiguously defined and recognisable, and specific enough to assign an effective intervention. Once PEAC events were identified, geospatial and predictive modelling of future events were then used to inform clinical service delivery, alongside appropriate return-on-investment analysis to support intervention. Finally, the entire process was embedded within a learning health system, linking research, policy, and practice, to drive ongoing improvement.ResultsExemplar PEAC events will be described, including hospital admission events associated with chronic disease, mental health, and dental/oral health. The predictability of such events in individuals using statistical models fitted to the available administrative datasets will be presented, along with the sequelae of such events in terms of healthcare use and mortality. The optimisation of delivering interventions targeting PEAC events will be described, along with the process of translating findings into policy and practice within the context of a learning health system.ConclusionThe identification of PEAC events allows for targeted delivery of healthcare interventions in a manner that not only optimises access, equity, and outcomes, but also permits ongoing improvement of the health system.

Hospital use in Aboriginal and non-Aboriginal patients with chronic disease

OBJECTIVE

The objective of this study was to compare rates of hospital utilisation in Aboriginal and non-Aboriginal peoples before and after hospital admission for chronic obstructive pulmonary disease, heart failure and/or type 2 diabetes mellitus.

METHODS

This was a longitudinal cohort study from 2002 to 2014, which was conducted in all hospitals in Western Australia. The participants of this study were Aboriginal and non-Aboriginal patients with a principal diagnosis of heart failure, type 2 diabetes or chronic obstructive pulmonary disease, on admission to hospital, where such an event had not occurred in the previous 3 years. Inpatient days and ED presentations were the main outcome measures.

RESULTS

Among the patients with chronic disease, Aboriginal people have similar inpatient days for all causes compared to non-Aboriginal people. However, they have much higher ED presentations in comparison. Age of onset of cardinal events occurs 15-20 years earlier in Aboriginal patients with chronic disease. Although age has little influence on ED presentations in non-Aboriginal chronic disease patients, younger Aboriginal people with chronic disease present far more often to ED than older Aboriginal people.

CONCLUSIONS

Aboriginal people use health services in a different manner when compared to non-Aboriginal people. In a subset of patients with chronic disease, high use may be reduced with better access to primary healthcare. Policy-makers and healthcare providers should examine healthcare use from primary to tertiary care among the Aboriginal population, with a particular focus on ED presentations; investigate the underlying causes driving specific patterns of health service utilisation among Aboriginal people; and develop interventions to reduce potential deleterious impacts, and enhance the potential benefits, of specific patterns of healthcare use.

Evaluation of the first pharmacist-administered vaccinations in Western Australia: a mixed-methods study

OBJECTIVES

This study evaluated the uptake of Western Australian (WA) pharmacist vaccination services, the profiles of consumers being vaccinated and the facilitators and challenges experienced by pharmacy staff in the preparation, implementation and delivery of services.

DESIGN

Mixed-methods methodology with both quantitative and qualitative data through surveys, pharmacy computer records and immuniser pharmacist interviews.

SETTING

Community pharmacies in WA that provided pharmacist vaccination services between March and October 2015.

PARTICIPANTS

Immuniser pharmacists from 86 pharmacies completed baseline surveys and 78 completed exit surveys; computer records from 57 pharmacies; 25 immuniser pharmacists were interviewed.

MAIN OUTCOME MEASURES

Pharmacy and immuniser pharmacist profiles; pharmacist vaccination services provided and consumer profiles who accessed services.

RESULTS

15 621 influenza vaccinations were administered by immuniser pharmacists at 76 WA community pharmacies between March and October 2015. There were no major adverse events, and <1% of consumers experienced minor events which were appropriately managed. Between 12% and 17% of consumers were eligible to receive free influenza vaccinations under the National Immunisation Program but chose to have it at a pharmacy. A high percentage of vaccinations was delivered in rural and regional areas indicating that provision of pharmacist vaccination services facilitated access for rural and remote consumers. Immuniser pharmacists reported feeling confident in providing vaccination services and were of the opinion that services should be expanded to other vaccinations. Pharmacists also reported significant professional satisfaction in providing the service. All participating pharmacies intended to continue providing influenza vaccinations in 2016.

CONCLUSIONS

This initial evaluation of WA pharmacist vaccination services showed that vaccine delivery was safe. Convenience and accessibility were important aspects in usage of services. There is scope to expand pharmacist vaccination services to other vaccines and younger children; however, government funding to pharmacists needs to be considered.

An intelligent interface for online interaction

In this paper, the author discusses the ways of improving the performance of online retrieval systems by introducing an automated interface between the enquirer and the system. In the first part of the paper, the main features of such human/machine interaction and the characteristics that the user would like to see incorporated in an interface, are de scribed. Then, studies in artificial intelligence that are particu larly relevant to the problems of implementing an intelligent interface, are discussed. The author concludes with a summary of automated mechanisms that will be needed to improve the quality of interaction between the user and the search system.

Eight challenges faced by general practitioners caring for patients after an acute coronary syndrome

The general practitioner is essential in the management of the patient who has recently been discharged from hospital following an acute coronary syndrome (ACS), particularly as duration of hospital stay is shorter than in previous decades. GPs caring for patients after an ACS face numerous challenges. Often, the first of these is insufficient or delayed documentation from the discharging hospital, although electronic discharge summaries are alleviating this problem. Post-ACS patients often have comorbidities, and GPs play a key role in managing these. Patients taking dual antiplatelet therapy who need surgery, and post-ACS patients with atrial fibrillation, require particular care from GPs. Patients will often approach their GP for advice on the safety of other drugs, such as smoking cessation medication, and phosphodiesterase type 5 inhibitors for erectile dysfunction. For patients complaining of persistent lethargy after an ACS, GPs must consider several differential diagnoses, including depression, hypotension, hypovolaemia, and side effects of β-blockers. GPs play an important ongoing role in ensuring that target cholesterol levels are reached with statin therapy; this includes ensuring long-term adherence. They may also need to advise patients who want to stop statin therapy, usually due to perceived side effects. Many of these challenges can be met with improved and respectful communication between the hospital, the treating cardiologist and the GP. The patient needs to be closely involved in the decision-making process, particularly when balancing the risks of bleeding versus thrombosis.

Choppers to optimise the repetition rate multiplication technique on a direct geometry neutron chopper spectrometer

In recent years the use of repetition rate multiplication (RRM) on direct geometry neutron spectrometers has been established and is the common mode of operation on a growing number of instruments. However, the chopper configurations are not ideally optimised for RRM with a resultant 100 fold flux difference across a broad wavelength band. This paper presents chopper configurations that will produce a relative constant (RC) energy resolution and a relative variable (RV) energy resolution for optimised use of RRM. The RC configuration provides an almost uniform ΔE/E for all incident wavelengths and enables an efficient use of time as the entire dynamic range is probed with equivalent statistics, ideal for single shot measurements of transient phenomena. The RV energy configuration provides an almost uniform opening time at the sample for all incident wavelengths with three orders of magnitude in time resolution probed for a single European Spallation Source (ESS) period, which is ideal to probe complex relaxational behaviour. These two chopper configurations have been simulated for the Versatile Optimal Resolution direct geometry spectrometer, VOR, that will be built at ESS.

The ecological fallacy of the role of age in chronic disease and hospital demand

OBJECTIVE

To examine the relationship between age and all-cause hospital utilization in the years preceding and following a diagnosis in hospital of heart failure, type 2 diabetes, or chronic obstructive pulmonary disease (COPD).

RESEARCH DESIGN

A cohort study of all patients in Western Australia who have had a principal diagnosis of heart failure, type 2 diabetes, or COPD, upon admission to hospital. All-cause hospital utilization 6 years preceding and 4 years following cardinal events, that is, a disease-specific diagnosis upon hospital admission, where such an event has not occurred in the previous 2 years, are examined in specific age groups.

RESULTS

Six years preceding a cardinal event, all-cause emergency department (ED) presentations are similar in all age groups, from under 55 to over 85 years of age, except in COPD where ED presentation rates are higher in younger groups. All-cause hospital inpatient days are transiently higher in the years preceding and following a cardinal event in older age groups, yet return to similar levels across all age cohorts after 4 years. ED presentations are significantly higher in the 4 years following cardinal events in younger compared with older groups.

CONCLUSIONS

Longitudinal analysis of utilization around cardinal events overcomes the confounding effect of differences in chronic disease rates between age groups, avoiding a source of ecologic bias that erroneously attributes increasing utilization in individuals with chronic disease to age. Programs designed to reduce hospital demand in patients with chronic disease should possibly focus on younger, rather than older, individuals.

General practice registrar teaching roles - is there a need for shared understanding?

BACKGROUND

There is currently a shortage of general practitioners and an increase in the number of medical students and general practice trainees. The expanded involvement of general practice registrars in teaching roles has been suggested as part of the solution to increasing the number of teaching roles in general practice.

METHODS

Survey and interviews of 273 GPs and 84 registrars mapping barriers to, and potential for, general practice registrar teaching capacity in Western Australia.

RESULTS

Results showed that 52.1% of GPs and 77.1% of registrars agreed that general practice registrars could increase teaching roles in general practice settings, but the two groups differed in their views about the scope of such teaching.

DISCUSSION

This study reports on the congruence and difference in views between GPs and registrars concerning the capacity for and scope of general practice registrar teaching in the general practice setting. There is a need to negotiate and identify the most appropriate general practice registrar teaching roles with both groups.

Teaching psychiatry in general practice

Clinical psychiatry in Australia has predominantly been taught to undergraduates through hospital based attachments. In response to rapid increases in medical student numbers at the University of Western Australia, the School of Primary, Aboriginal and Rural Health Care began a collaboration with an outer urban hospital to integrate community general practice based psychiatry with a hospital based clinical attachment and to improve educational capacity at the hospital.

Community acquisition of gentamicin-sensitive methicillin-resistant Staphylococcus aureus in southeast Queensland, Australia

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) susceptible to gentamicin has been reported in a number of countries in the 1990s. To study the acquisition of gentamicin-sensitive MRSA (GS-MRSA) in southeast Queensland and the relatedness of GS-MRSA to other strains of MRSA, 35 cases of infection due to GS-MRSA from October 1997 through September 1998 were examined retrospectively to determine the mode of acquisition and risk factors for MRSA acquisition. Thirty-one isolates from the cases were examined using a variety of methods (antibiotyping, phage typing, pulsed-field gel electrophoresis [PFGE] fingerprinting, and coagulase typing by restriction analysis of PCR products) and were compared with strains of local hospital-acquired gentamicin-resistant MRSA (GR-MRSA) and of Western Australian MRSA (WA-MRSA). Only 6 of 23 cases of community-acquired GS-MRSA had risk factors for MRSA acquisition. Twenty of 21 isolates from cases of community-acquired infection were found to be related by PFGE and coagulase typing and had similar phage typing patterns. Hospital- and nursing home-acquired GS-MRSA strains were genetically and phenotypically diverse. Community-acquired GS-MRSA strains were not related to nosocomial GR-MRSA or WA-MRSA, but phage typing results suggest that they are related to GS-MRSA previously reported in New Zealand.

Evolution of an endemic methicillin-resistant Staphylococcus aureus population in an Australian hospital from 1967 to 1996

The evolution over 30 years of a population of methicillin-resistant Staphylococcus aureus (MRSA) from a tertiary referral hospital was studied by phylogenetic analysis of SmaI-generated restriction fragment length polymorphisms (RFLPs). The results suggest that a new clone of MRSA appeared at the hospital in the early 1980s, which, although usually retaining its ancestral phage-type, developed four different RFLP pulsotypes in the next 16 years. This finding indicates that multiple RFLP patterns in MRSA do not necessarily represent multiple clones deriving from different mec gene transfer events. Such variation within a clone may be significant in the interpretation of RFLP patterns during outbreaks and emphasizes the need to use two typing methods in studies of such populations. Since the appearance of new clones of MRSA is a relatively rare event, cross-infection control is paramount in the prevention of MRSA dissemination.

Evaluation of a decision support system for pressure ulcer prevention and management: preliminary findings

A decision support system for prevention and management of pressure ulcers was developed based on AHCPR guidelines and other sources. The system was implemented for 21 weeks on a 20-bed clinical care unit. Fifteen nurses on that unit volunteered as subjects of the intervention to see whether use of the system would have a positive effect on their knowledge about pressure ulcers and on their decision-making skills related to this topic. A similar care unit was used as a control. In addition, the system was evaluated by experts for its instructional adequacy, and by end users for their satisfaction with the system. Preliminary results show no effect on knowledge about pressure ulcers and no effect on clinical decision making skills. The system was rated positively for instructional adequacy, and positively for user satisfaction. User interviews related to satisfaction supplemented the quantitative findings. A discussion of the issues of conducting experiments like this in today's clinical environment is included.

Methicillin-resistant Staphylococcus aureus in a cystic fibrosis unit

Methicillin-resistant Staphylococcus aureus (MRSA) infection in a cystic fibrosis (CF) unit was investigated. Two typing methods, phage-typing and restriction fragment length polymorphism (RFLP) by pulsed-field gel electrophoresis (PFGE) and phylogenetic analysis, showed that nonsocomial transmission of MRSA from the general hospital population had occurred. One instance of possible transmission between two patients was identified. However, transmission between two family members did not occur indicating a minimal risk of MRSA acquisition from social contact compared with hospital admission. This study supports policies for limiting CF-patient admission to hospital but transmission of MRSA does not appear to be a reason for limiting social contact with other CF patients.

A knowledge-based decision support system for prevention and treatment of pressure ulcers

As part of a research project intended to provide problem-based knowledge to clinicians at the point of care, we have developed a system that supports the nurse's development of patient-specific, guideline-based treatment plans for patients who have pressure ulcers or are at risk for developing them. The system captures coded data about assessment, diagnosis and interventions using a point-and-click interface. Knowledge is accessible to the user via: 1) hypertext links from the data entry screens; 2) explicit entry into an indexed version of the guideline; 3) imbedded knowledge-based rules that critique the diagnosis and offer guidance for treatment; and 4) explicit entry into interactive algorithms. The system has been implemented experimentally on one care unit at our hospital, where its impact will be assessed in comparison with a control unit. Data on 113 patients were entered during the 21-week experimental period. The system is being evaluated for its instructional adequacy, its impact on clinicians' decision-making and knowledge, and on processes of care. Users' perceptions of the system are also being evaluated. Dissemination issues in the context of today's health care environment are addressed.

Typing multidrug-resistant Staphylococcus aureus: conflicting epidemiological data produced by genotypic and phenotypic methods clarified by phylogenetic analysis

An outbreak of an unusual tetracycline-sensitive, rifampicin- and ciprofloxacin-resistant, methicillin-resistant Staphylococcus aureus (MRSA) strain at a large teaching hospital was investigated. Two typing methods, phage typing and restriction fragment length polymorphism (RFLP) by pulsed-field gel electrophoresis (RFLP-PFGE), gave conflicting results which were clarified by phylogenetic analysis. Phage typing identified all the "epidemic-associated" strains as identical, while RFLP-PFGE further divided these strains into four pulsotypes. Phylogenetic analysis showed these four pulsotypes were related genetically and also recognized a second strain of MRSA causing a continuing cross-infection problem. Variation in the RFLP-PFGE pattern was shown to occur following lysogenization of phage-sensitive MRSA. These results indicate that in analyzing outbreaks caused by subgroups of clonal organisms like MRSA, it is necessary to use at least two typing methods and that conflicts between these could be resolved by phylogenetic analysis.

A decision support system for prevention and treatment of pressure ulcers based on AHCPR guidelines

We have developed a Pressure Ulcer Prevention and Management System to assist clinicians with patient-specific decision making. The system captures coded data about assessment, diagnosis and interventions using a point-and-click interface. Guideline-based knowledge is imbedded into the system, and is accessible in several ways: 1) via hypertext links from the data entry screens; 2) via explicit entry into an indexed version of the guideline; 3) via imbedded knowledge-based rules that critique the diagnosis and offer guidance for treatment; and 4) via explicit entry into interactive algorithms. The system has been implemented experimentally on one care unit at our hospital, where its impact will be assessed in comparison with a control unit. Preliminary usage data are provided. Issues with rendering guideline material useful for patient-specific decision support are discussed. In our setting, these issues had to do with a) incongruity with local standards; b) insufficient specificity; and 3) insufficient comprehensiveness. Issues of use and dissemination in the context of today's health care environment are also addressed.

Nasal carriage of Staphylococcus aureus in Australian (pre-clinical and clinical) medical students

The nasal carriage of Staphylococcus aureus in 808 Australian medical students was studied. Five groups of students experienced varying degrees of clinical exposure in a hospital environment ranging from 0 to 42 months. The overall percentage of carriers among the five groups did not vary. However, with increasing clinical exposure there was a decrease in the percentage of isolates sensitive to all antibiotics tested, and an increase in the carriage of S. aureus resistant to three or more antibiotics. No carriers of methicillin-resistant S. aureus (MRSA) were detected. The comparative rates of S. aureus carriage between female and male students varied. The relevance of medical students as nasal carriers of S. aureus in the hospital environment today is discussed.

Epidemiological analysis of a methicillin-resistant Staphylococcus aureus outbreak using restriction fragment length polymorphisms of genomic DNA

The genomic DNA of 58 isolates of methicillin-resistant Staphylococcus aureus (MRSA) obtained during an infection outbreak at two major Canberra hospitals was analysed for restriction fragment length polymorphism (RFLP) by digestion with the endonuclease SmaI and resolution of the fragments by pulsed-field gel electrophoresis. Based on the fraction of common fragments generated by the endonuclease, DNA similarities among the isolates were estimated. Distance matrix analysis showed that the MRSA isolates could be divided into two major clusters (RFLP types I and II) and one minor one (type 46). A fourth group of miscellaneous isolates was found to be heterogeneous in terms of DNA sequence similarity. The epidemiological data indicated that RFLP type I was most common in the intensive care units in the two hospitals, with particular subtypes of RFLP type I concentrated in individual units. RFLP type II and the miscellaneous group were more generally distributed. Type 46 isolates appear to be related to a group which was present in epidemics in Melbourne hospitals in the early 1980s. Using the standard phage set, the RFLP type I group was largely untypable. However, type II isolates were all phage typable, with a shared susceptibility to phages 29/85/95/90; type 46 isolates had a shared susceptibility to phages 85/90. The miscellaneous isolates were of variable phage types.

Serological typing of coagulase-negative staphylococci using monoclonal antibodies

This investigation was to determine whether monoclonal antibodies (Mabs) could be used to differentiate coagulase-negative staphylococci (C-NS) at species and strain level. Mabs were produced to four Staphylococcus epidermidis strains, two S. haemolyticus strains, one S. saprophyticus strain and one S. warneri strain. A panel of nine antibodies was tested for species and strain specificity against five type strains and 65 clinical isolates of C-NS by enzyme-linked immunosorbent assay (ELISA). Species specificity was found with Mab D150 produced to one S. haemolyticus strain. Using Mab D150 and Mab D198 in conjunction, identification of 90% of S. haemolyticus isolates to species level was achieved. S. saprophyticus Mab K84 reacted with most other strains of C-NS tested but only three S. haemolyticus strains (16%). This finding provides further evidence that S. haemolyticus possesses different surface determinants to other C-NS which could form the basis of a typing scheme for S. haemolyticus using Mabs D150, D198 and K84.

Prevalence of peritonitis-associated coagulase-negative staphylococci on the skin of continuous ambulatory peritoneal dialysis patients

The predominance of coagulase-negative staphylococci as normal skin flora is thought to be a factor in their association with episodes of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. We investigated the prevalence of peritonitis-associated strains on the skin of 28 patients undergoing peritoneal dialysis. Coagulase-negative staphylococci were the most frequently isolated organisms, comprising 47% of peritoneal dialysis fluid isolates and 59% of body site isolates. A total of 142 coagulase-negative staphylococci were speciated, tested for their antimicrobial sensitivity and slime production, and identified by phage typing and plasmid-profile analysis. Staphylococcus epidermidis was the most commonly identified species from both peritoneal dialysis fluid (73%) and body sites (53%). Multiple antibiotic resistance was common, and the greater proportion of isolates were resistant to methicillin; 63.6% of peritoneal dialysis fluid isolates and 61.7% of body-site isolates. S. haemolyticus isolates were significantly more resistant to methicillin than other species. By phage typing and plasmid-profile analysis it was shown that peritonitis was rarely caused by skin-colonizing strains. In only 3 of 14 patients were peritonitis-associated strains isolated as skin colonizers, and no patients developed peritonitis due to organisms previously isolated as skin colonizers.