The role of collaborative decision-making in discharge planning: Perspectives from patients, family members and health professionals

AIM

To explore discharge planning with a range of key stakeholders in subacute care, including consumers.

DESIGN

Qualitative descriptive study.

METHODS

Patients (n = 16), families (n = 16), clinicians (n = 17) and managers (n = 12) participated in semi-structured interviews or focus groups. Following transcription, data were analysed thematically.

RESULTS

The overarching facilitator of effective discharge planning was collaborative communication, leading to shared expectations by all stakeholders. Collaborative communication was underpinned by four key themes: patient- and family-centred decision-making, early goal setting, strong inter- and intra-disciplinary teamwork, and robust patient/family education.

CONCLUSION

Effective planning for discharge from subacute care is enabled by shared expectations and collaborative communication between key stakeholders.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Effective discharge planning processes are underpinned by effective inter- and intra-disciplinary teamwork. Healthcare networks should foster environments that promote effective communication between and within multidisciplinary team members as well as with patients and their families. Applying these principles to discharge planning may assist in reducing length of stays and rates of preventable readmissions post-discharge.

IMPACT

This study addressed a lack of knowledge about effective discharge planning in Australian subacute care. It found that collaborative communication between stakeholders was an overarching facilitator of effective discharge planning. This finding impacts subacute service design and professional education.

REPORTING METHOD

COREQ guidelines were followed in reporting this study.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution in the design, data analysis or preparation of the manuscript.

Defining ready for discharge from sub-acute care: a qualitative exploration from multiple stakeholder perspectives

BACKGROUND

Planning discharges from subacute care facilities is becoming increasingly complex due to an ageing population and a high demand on services. The use of non-standardised assessments to determine a patient's readiness for discharge places a heavy reliance on a clinician's judgement which can be influenced by system pressures, past experiences and team dynamics. The current literature focusses heavily on discharge-readiness from clinicians' perspectives and in the acute care setting. This paper aimed to explore the perceptions of discharge-readiness from the perspectives of key stakeholders in subacute care: inpatients, family members, clinicians and managers.

METHODS

A qualitative descriptive study was conducted, exploring the views of inpatients (n = 16), family members (n = 16), clinicians (n = 17) and managers (n = 12). Participants with cognitive deficits and those who did not speak English were excluded from this study. Semi-structured interviews and focus groups were conducted and audio-recorded. Following transcription, inductive thematic analysis was completed.

RESULTS

Participants identified that there are both patient-related and environmental factors that influence discharge-readiness. Patient-related factors discussed included continence, functional mobility, cognition, pain and medication management skills. Environmental factors centred around the discharge (home) environment, and were suggested to include a safe physical environment alongside a robust social environment which was suggested to assist to fill any gaps in functional capabilities (i.e. patient-related factors).

CONCLUSIONS

These findings make a unique contribution to the literature by providing a thorough exploration of determining discharge-readiness as a combined narrative from the perspectives from key stakeholders. Findings from this qualitative study identified key personal and environmental factors influencing patients' discharge-readiness, which may allow health services to streamline the determination of discharge-readiness from subacute care. Understanding how these factors might be assessed within a discharge pathway warrants further attention.

Digital Health Literacy as a Predictor of Awareness, Engagement, and Use of a National Web-Based Personal Health Record: Population-Based Survey Study

Background

Web-based personal health records (PHRs) have the potential to improve the quality, accuracy, and timeliness of health care. However, the international uptake of web-based PHRs has been slow. Populations experiencing disadvantages are less likely to use web-based PHRs, potentially widening health inequities within and among countries.

Objective

With limited understanding of the predictors of community uptake and use of web-based PHR, the aim of this study was to identify the predictors of awareness, engagement, and use of the Australian national web-based PHR, My Health Record (MyHR).

Methods

A population-based survey of adult participants residing in regional Victoria, Australia, was conducted in 2018 using telephone interviews. Logistic regression, adjusted for age, was used to assess the relationship among digital health literacy, health literacy, and demographic characteristics, and the 3 dependent variables of MyHR: awareness, engagement, and use. Digital health literacy and health literacy were measured using multidimensional tools, using all 7 scales of the eHealth Literacy Questionnaire and 4 out of the 9 scales of the Health Literacy Questionnaire.

Results

A total of 998 responses were analyzed. Many elements of digital health literacy were strongly associated with MyHR awareness, engagement, and use. A 1-unit increase in each of the 7 eHealth Literacy Questionnaire scales was associated with a 2- to 4-fold increase in the odds of using MyHR: using technology to process health information (odds ratio [OR] 4.14, 95% CI 2.34-7.31), understanding of health concepts and language (OR 2.25, 95% CI 1.08-4.69), ability to actively engage with digital services (OR 4.44, 95% CI 2.55-7.75), feel safe and in control (OR 2.36, 95% CI 1.43-3.88), motivated to engage with digital services (OR 4.24, 95% CI 2.36-7.61), access to digital services that work (OR 2.49, 95% CI 1.32-4.69), and digital services that suit individual needs (OR 3.48, 95% CI 1.97-6.15). The Health Literacy Questionnaire scales of health care support, actively managing health, and social support were also associated with a 1- to 2-fold increase in the odds of using MyHR. Using the internet to search for health information was another strong predictor; however, older people and those with less education were less likely to use MyHR.

Conclusions

This study revealed strong and consistent patterns of association between digital health literacy and the use of a web-based PHR. The results indicate potential actions for promoting PHR uptake, including improving digital technology and skill experiences that may improve digital health literacy and willingness to engage in web-based PHR. Uptake may also be improved through more responsive digital services, strengthened health care, and better social support. A holistic approach, including targeted solutions, is needed to ensure that web-based PHR can realize its full potential to help reduce health inequities.

471 Assessing the Accuracy and Bias of Digital Symptom Checkers with Myocardial Infarction Patients

Aim

The accuracy and safety of symptom checkers in diagnosing and triaging patients is of concern; especially those with life-threatening conditions. The study's aims were to: 1. assess the accuracy of symptom checkers in diagnosing and triaging myocardial infarctions (MI) and, 2. determine whether differences in gender or presentation type exist.

Method

This prospective diagnostic accuracy study assessed 8 symptom checkers using 100 MI patients of various presentations: typical or atypical. The ability of a symptom checker in providing MI as the first diagnosis (D1) and the first 3 (D3) diagnoses were diagnostic accuracy measures. Triage advice was deemed correct if the symptom checker recommended seeking emergency treatment.

Results

Symptom checkers correctly diagnosed 48.0±31.4% of cases with MI first. D3 accuracy was 72.6±20.2%. Mean triage accuracy was 82.6±12.6%.

24.0±16.2% of atypical cases had a correct primary diagnosis. D3 accuracy for atypical MI was 43.8±20.6%, significantly lower than that of typical MI (p<0.01). Atypical case triage accuracy was 52.7±20.0%, significantly lower than typical cases (84.2±14.7%, p<0.01).

10.0% of the atypical female cases were diagnosed correctly with MI as the first diagnosis. Female atypical cases had significantly lower accuracy than typical female cases for all accuracy measures (p<0.01).

Conclusions

Symptom checkers generally provide low accuracy for diagnosing MI. Approximately 20% of cases were under-triaged. Results varied between symptom checkers: patients who presented with atypical symptoms tended to be under-diagnosed and under-triaged, especially those who were female. This demonstrated potential gender bias and therefore raises questions regarding symptom checker regulation and safety.

O024 Prognostic value of haemodynamic parameters in predicting adverse clinical events in type B aortic dissection

Introduction

Ascertain the prognostic role of in-vivo 4D-flow magnetic resonance imaging (MRI) and computational fluid dynamics (CFD) aortic haemodynamic parameters as predictors of adverse dissection-related events in type B aortic dissection (TBAD).

Methods

A systematic literature search was conducted according to the PRISMA guidelines using electronic databases searched from 1946 to 2021 for studies reporting on the relationship between aortic haemodynamics and aortic dissection-related events defined as aortic growth, aneurysm development, false lumen thrombosis, need for surgery and aortic rupture.

Results

Fourteen studies were included; eleven studies used CFD and three studies used 4D-flow MRI. Two studies found increased FL ejection fraction (EF) significantly associated with aortic growth rate, and another study found increased FL stroke volume significantly associated with increased aortic expansion rate. Result for time-averaged wall shear stress (TAWSS) and relative residence time (RRT) are contradictory; one study found TAWSS significantly associated with aortic wall deformation, but another study found no significant difference. Five studies suggested possible associations between slow flowing regions or increased RRT and FL thrombosis, with another study finding significant associations between FL thrombosis and adverse aortic outcomes. However, one study revealed opposite findings where decreased RRT significantly correlated with aneurysm formation.

Conclusion

In-vivo aortic haemodynamic measurements such as FL EF, FL stroke volume, TAWSS and RRT show possible associations with FL and aortic expansion, as well as FL thrombosis. Larger prospective studies are now needed to determine the prognostic utility of in vivo aortic haemodynamic metrics in predicting TBAD clinical outcomes to guide management.

Take-home message

Aortic haemodynamic parameters measured by 4D-flow magnetic resonance imaging and computational fluid dynamics show promising potential as predictors of adverse dissection-related events in type B aortic dissection.

Evaluating old truths: Final adult size in holometabolous insects is set by the end of larval development

For centuries, it has been understood that the final size of adult holometabolous insects is determined by the end of the larval stage, and that once they transform to adults, holometabolous insects do not grow. Despite this, no previous study has directly tested these "old truths" across holometabolous insects. Here, we demonstrate that final adult size is set at the end of the last larval stage in species representing each of the four orders of holometabolous insects: the fruit fly Drosophila melanogaster (Diptera), the tobacco hornworm Manduca sexta (Lepidoptera), the dung beetle Onthophagus taurus (Coleoptera), and the Florida carpenter ant Camponotus floridanus (Hymenoptera). Furthermore, in both D. melanogaster and C. floridanus, we show that the size of adult individuals fluctuates but does not significantly change. Therefore, our study finally confirms these two basic assumptions in the biology of insects, which have for centuries served as the foundation for studies of insect growth, size, and allometry.

Digital patient-reported outcomes in inflammatory bowel disease routine clinical practice: the clinician perspective

Background

Use of digital health services, such as digital patient-reported outcomes, depends on many different human factors as well as digital design solutions. One factor is clinicians’ attitude towards the system, their reasoning behind the using system and their perceptions of patients’ ability to engage with digital health systems. This study aimed to explore hospital clinicians’ attitudes towards digital patient-reported outcomes used in the routine care and treatment of inflammatory bowel disease, and to explore the potential role of clinicians’ attitudes in influencing patients’ use of digital patient-reported outcomes.

Results

Twelve clinicians using digital patient-reported outcome assessments in the care of inflammatory bowel disease were interviewed about their experiences of, and perspectives on, using this service. Most participants supported the use of digital patient-reported outcome assessments in the care of most patients. Participants reported that most patients found the digital solution easy to use. They perceived digital patient-reported outcomes to have three main purposes: prioritising resources; improving patients’ quality of life; and improving quality of care. The patient-clinician relationship was of great importance to participants. Participants varied in their intention to use digital PRO, as some viewed the system as a positive but optional add-on for patients, whilst others intended to use the system with all eligible patients.

Conclusion

Clinicians’ general support of using digital patient-reported outcomes might facilitate their use among patients with inflammatory bowel disease. The participants saw benefits in doing so for patients, clinicians and the wider health service. Clinicians’ attitudes towards the use of digital PRO in the care of their patients may influence patients’ uptake of health service.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00462-x.

Readiness, acceptance and use of digital patient reported outcome in an outpatient clinic

Use of digital patient-reported outcomes is being introduced in care of chronic conditions, including Inflammatory Bowel Disease. The aim is to supplement face-to-face follow-up sessions through symptom screening, and to inform follow-up through questions about mental health and quality of life. However, little is known about who is using this as intended. This study aimed to map differences between users and non-users among people with IBD and explore the mechanisms behind. We administered a questionnaire including the Readiness and Enablement Index for Health Technology (ReadHy) and the Service User Technology Acceptability Questionnaire (SUTAQ) to all people with IBD registered at Silkeborg Regional Hospital. Comparison between users and non-users and cluster analysis was conducted. Effect size (Cohen's d) was used to estimate magnitude of difference between groups. The user and non-user groups differed most strongly by level of emotional distress (d = 0.45). Cluster analysis of the ReadHy scales showed profiles have different sets of difficulties and reservations towards digital solutions. These difficulties correlated moderately with SUTAQ dissatisfaction and low acceptability. The dimensions of ReadHy may help to better understand particular needs of people with IBD when accessing digital PROs, which may lead to higher acceptability and improved quality of care.

The detection of germline and somatic BRCA1/2 genetic variants through parallel testing of patients with high-grade serous ovarian cancer: a national retrospective audit

Objective

To determine the frequency of germline and somatic pathogenic BRCA1 and BRCA2 variants in patients with high‐grade serous ovarian cancer tested by next‐generation sequencing (NGS), with the aim of defining the best strategy to be implemented in future routine testing.

Design

National retrospective audit.

Setting

The All Wales Medical Genomics Service (AWMGS).

Population

Patients with high‐grade serous ovarian/fallopian tube/peritoneal cancer referred by oncologists to the AWMGS between February 2015 and February 2021 for germline and/or tumour testing of the BRCA1 and BRCA2 genes by NGS.

Methods

Analysis of NGS data from germline and/or tumour testing.

Main outcome measures

Frequency of BRCA1 and BRCA2 pathogenic variants.

Results

The overall observed germline/somatic pathogenic variant detection rate was 11.6% in the 844 patients included in this study, with a 9.2% (73/791) germline pathogenic variant detection rate. Parallel tumour and germline testing was carried out for 169 patients and the overall pathogenic variant detection rate for this cohort was 14.8%, with 6.5% (11/169) shown to have a somatic pathogenic variant. Two BRCA1 dosage variants were found during germline screens, representing 2.0% (2/98) of patients with a pathogenic variant that would have been missed through tumour testing alone.

Conclusions

Parallel germline and tumour BRCA1 and BRCA2 testing maximises the detection of pathogenic variants in patients with high‐grade serous ovarian cancer.

Tweetable abstract

Parallel germline and tumour testing maximises BRCA pathogenic variant detection in ovarian cancer.

Parallel germline and tumour testing maximises BRCA pathogenic variant detection in ovarian cancer.

Linked article This article is commented on by C Gourley, p. 443 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471-0528.16978.

324 Outcomes of Prostate Artery Embolisation In Catheterised Patients: A Case Series

Aim

Prostate artery embolisation (PAE) is an approved treatment for men with lower urinary tract symptoms secondary to benign prostatic hyperplasia (BPH-LUTS). Evidence of efficacy for PAE in patients who are unable to void urine spontaneously is scant, however. Traditional treatments for BPH-LUTS have evidence in retention patients and this series aims to report outcomes for PAE in catheterised patients.

Method

The records of consecutive men with BPH-LUTS which required either an indwelling bladder catheter or clean intermittent self-catheterisation (CISC) who subsequently underwent PAE were retrospectively reviewed. Basic demographics were collected along with information on the prostate volume and PAE procedure specifics. The primary outcome was whether patients were catheter/CISC free at 3 months. Other outcomes include complications, use of medications and the need for other surgical treatments post-PAE.

Results

63 men underwent PAE for urinary retention and BPH-LUTS between 2013 and 2020. Of these, 7 underwent a unilateral embolisation for aberrant anatomy. The mean prostate volume was 128ml. 61% of men were free from a catheter/CISC post-treatment. 4 patients suffered post-PAE UTI, whilst 3 patients subsequently underwent Transurethral Resection of the Prostate following PAE for failure to become catheter free. 13 men were entirely free from BPH-LUTS medications.

Conclusions

PAE for catheterised men results in a similar catheter-free rate post procedure to several more invasive BPH treatments. It has a low side-effect profile and gives men with poor health an option to try to become catheter free. PAE should be discussed with men with catheters as a treatment option.

Patient perspectives on digital patient reported outcomes in routine care of inflammatory bowel disease

Background

Digital patient reported outcomes are used increasingly in daily care and treatment of inflammatory bowel disease. Their purpose includes increased focus on patient wellbeing, reduction in avoidable follow-up consultations and increased patient self-management. However, implementation issues occur and studies indicate patients may have concerns, particularly regarding having fewer face-to-face consultations. This study aims to explore patients’ perspectives of use and non-use of digital patient reported outcomes and to understand the mechanisms underpinning patient reluctance to engage with this health technology.

Results

Sixteen patients with inflammatory bowel disease at a regional hospital in Denmark were interviewed about their experiences of, and perspectives on, digital patient reported outcomes. A certain level of eHealth literacy was found to be a fundamental condition for use, while other factors were barriers or facilitators for use of digital PROs. Patients’ main concerns were about potential consequences for their care and relationship with the clinic. Most patients in stable remission were satisfied with the hospital being a “life-line” if their symptoms worsened, and perceived digital patient reported outcomes to be an efficient tool to establish that “life-line”. Patients with severe symptoms and a high degree of emotional distress related to their disease valued the potential for digital patient reported outcomes to increase their clinicians’ focus on mental health and extra-intestinal symptoms.

Conclusion

This study found that if patients had sufficient digital literacy, they perceived digital patient reported outcomes to be a useful replacement for face-to-face consultations. However, they were concerned about digital patient reported outcomes’ effect on the patient–clinician relationship and its ability to detect worsening of symptoms. These concerns may be mitigated by good patient–clinician relationships, and the option for patients to maintain direct telephone contact with their gastroenterology specialist.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-021-00366-2.

‘Digital patient reported outcomes’ refer to systems by which health professionals collect health information from patients between consultations, mostly via self-completed online questionnaires. This approach aims to support treatment and disease management, and reduce avoidable face-to-face consultations between doctor and patient. However, patients may have concerns about using digital systems to communicate with their clinicians, particularly regarding having fewer face-to-face consultations. To find out more, we interviewed sixteen patients at an Inflammatory Bowel Disease outpatient clinic in Denmark, where digital Patient Reported Outcomes have been used since 2017. We found out that patients needed to have enough familiarity with technology to be able to use these online systems. Patients were worried about how this new way of communicating with the clinic affected their care and their relationship with their doctors and nurses. People with Inflammatory Bowel Disease can have long periods of time with very little disease activity, and in these stable periods, a lot of patients found that a digital Patient Reported Outcomes system was a good way to stay in touch with the clinic and keep reporting their symptoms online– as long as they still had the possibility of contacting the clinic by telephone if needed. During disease flare-ups, patients believed that digital patient reported outcomes’ could be used to give broader insight into their health situation, and trusted their clinicians to use their self-reported data to improve their care.

Dose-Volume Predictors for Patient-reported Late Diarrhoea, Faecal Incontinence and Urgency after Pelvic Radiotherapy

AIMS

Pelvic radiotherapy adds significantly to the curative treatment of many pelvic malignancies. However, this cure comes at a cost for many patients, where late bowel toxicities, such as faecal incontinence, urgency and diarrhoea, adversely affect quality of life. Despite the implementation of advanced radiotherapy techniques in many centres, there are deficiencies in our knowledge of how to make best use of these techniques to minimise these late toxicities, with dose-volume constraints specifically for late effects needing definition. The aims of this study were to establish dose-volume predictors for patient-reported late bowel toxicities and derive constraints for clinical use to reduce the risk of these toxicities.

MATERIALS AND METHODS

All radiotherapy patients treated in our institution between 2012 and 2014 for gynaecological and urological cancers (bladder, prostate where pelvic nodes are treated) were identified. Patients were sent patient-reported toxicity questionnaires at 12 and 24 months after treatment. Planning computed tomography scans were retrospectively contoured with different definitions of bowel as organs at risk (OARs). Dose-volume data for each OAR were collected and predictors of these toxicities found using multivariate analysis. For those dose-volume predictors found to be significant on multivariate analysis, statistically significant and clinically relevant dose-volume constraints were derived. Furthermore, data collected were used to validate constraints from published studies.

RESULTS

Faecal urgency, incontinence and diarrhoea rates were found in 52, 23.5 and 18.7% of the 203 patients included at 12 months following radiotherapy. Dose-volume parameters for sigmoid colon and large bowel were significant for these toxicities, and constraints for these OARs were derived, which are promising. A previously published constraint for bowel loops was validated with our data.

CONCLUSIONS

The sigmoid colon and large bowel are important OARs for the development of faecal urgency, incontinence and diarrhoea. Promising constraints for these OARs were derived, which require further validation before prospective clinical use.

The origin of wing polyphenism in ants: An eco-evo-devo perspective

The evolution of eusociality, where solitary individuals integrate into a single colony, is a major transition in individuality. In ants, the origin of eusociality coincided with the origin of a wing polyphenism approximately 160 million years ago, giving rise to colonies with winged queens and wingless workers. As a consequence, both eusociality and wing polyphenism are nearly universal features of all ants. Here, we synthesize fossil, ecological, developmental, and evolutionary data in an attempt to understand the factors that contributed to the origin of wing polyphenism in ants. We propose multiple models and hypotheses to explain how wing polyphenism is orchestrated at multiple levels, from environmental cues to gene networks. Furthermore, we argue that the origin of wing polyphenism enabled the subsequent evolution of morphological diversity across the ants. We finally conclude by outlining several outstanding questions for future work.

Identifying Risk Factors for Anthracycline Chemotherapy-induced Phlebitis in Women with Breast Cancer: An Observational Study

AIMS

Anthracycline chemotherapy administered via a peripheral cannula results in severe anthracycline chemotherapy-induced phlebitis (ACIP) in about 20-30% of patients. Administering chemotherapy via a central venous catheter (CVC) prevents ACIP. However, CVCs are associated with an increased risk of thrombosis and sepsis. Our aim was to identify risk factors associated with severe ACIP and to provide evidence about the individual risk of developing symptoms.

MATERIALS AND METHODS

A prospective observational study of 263 women with breast cancer receiving peripheral administration of anthracycline chemotherapy at a UK cancer centre was conducted between May 2016 and January 2018. Data were collected at baseline and every 3 weeks following each chemotherapy treatment, using both healthcare professional- and participant-reported symptom assessments.

RESULTS

After three cycles of chemotherapy, 27% of participants experienced severe ACIP. Factors associated with symptom severity were identified as: arm used for chemotherapy administration, epirubicin dose, age, pre-existing hypertension, comorbidity, ethnic group and pain during chemotherapy administration. The sequence of arm used for chemotherapy administration was the single most significant factor (P < 0.001). When alternating arms were used no other risk factor was influential. Where alternating arms were not used, younger age and higher dose were associated with higher-grade symptoms, with age being more influential than dose. The cumulative effect of increasing symptom severity with repeated cycles was also identified (P < 0.001).

CONCLUSION

It is recommended that a CVC is not routinely required for women with breast cancer who have not undergone an axillary node clearance and receive chemotherapy in alternate arms. The need for a CVC for women who are planned to receive all anthracycline chemotherapy cycles in the same arm should be assessed in the light of peripheral venous access assessment and the key risk factors of age, dose and number of cycles.

Climate change: past and projected threats to food and water security = public health emergency

Dr Liz Hanna chairs the Environmental Health Working Group of the WFPHA. For more than a decade she has researched climate change adaptation (CCA), focusing on exposure risks, physiological health impacts, health sector preparedness and policy responses to analyze current and future climate health threats. Working in Prof Tony McMichael's team at the Australian National University, she convened the National CCA Research Network, and served as President of the Climate and Health Alliance.

Human history is littered with examples of climatic interruptions to food and water supplies leading to disease and famine, conflict and migration. Dr Hanna sets the scene for this challenging workshop by outlining selected historical examples and describing the pathways of interconnectedness. Previously, climatic, health and social upheavals were geographically restricted. Yet the world now faces climatic change on a global scale never before it witnessed by humans. Liz outlines how this global disruption threatens our most important environmental determinants of health.

Evidence of global warming acceleration is presented and linked with disruptions to vital ecosystems and interruptions to food and water resources. Dr Hanna then leads participants on a journey to the future by applying IPCC projections to demonstrate the escalated potential for health harm from further intensified disturbances to the hydrological patterns, ocean warming, acidification and sea level rise, global heating and increased heat extremes as these impact water sources, crop yields, stock health and their survival, the marine food web and human acclimatisation limitations.

Throughout this presentation, Dr Hanna weaves the interconnectedness of healthy ecosystems and healthy people, and our global interconnectedness as we collectively share this beautiful but fragile planet.

Australia’s 2020 summer shows our changed climate future - a public health preparedness challenge

Background

Humans have wandered this planet for hundreds of thousands of years, yet in the last 160 years we have dramatically disrupted planetary systems upon which we depend. Humanity has polluted the oceans, rivers, air and soils. Our persistent burning of fossil fuels to power opulent lifestyles is now perilously close to permanently disrupting global climatic systems.

Problem

It is clear. The problem is us. Australia's summer of horrors provides a terrifying glimpse into our collective future. This rich and exquisitely advantaged nation has voted for governments that have ignored fragile ecosystems, dismantled environmental protection laws, ignored climate science and expanded its fossil fuel exploration, extraction, consumption and exportation. It has systematically silenced science, ignored its duty of care to protect its present and future citizenry.

Evidence

The 2019-2020 summer brought unprecedented disasters to a country familiar with disasters. After the hottest and driest year on record came the world's largest bushfire, which started in winter, and burned uncontainable for 7 months across 5 states. Billions of animals perished, thousands of homes & businesses destroyed, 33 people burned alive. Continental-wide temperatures of 42oC. Smoke levels exceeded hazardous levels by a factor of 25, lingered 6weeks in the national capital, circumnavigated the southern hemisphere. 80% of Australians were affected by the fires in some way, and the nation fell into a deep grief.

The public health challenge

As the world faces new climate regimes, the associated health challenges are elevating to unheralded and unforeseen levels. Public health preparedness for past situations will inevitably fail. Events are no longer singular, short lived or readily managed. Today's events are multifaceted, expansive and protracted. Their sheer magnitude and scale prevent response activities, interrupt transport and supply chains and shut down power and communications.

Key messages

Unfettered human development has degraded planetary systems upon which humanity depends for survival and flourishing. Climate change is disrupting all our key environmental determinants of health. Environmental degradation and climate change now present a rapidly intensifying health emergency. Australia’s summer of disasters demonstrates we need an explosion of public health preparedness.

Overestimation of heat tolerance calls for health promotion to limit occupational heat risk

Background

Global warming is accelerating. One degree C warming across Australia has generated a six-fold increase in heat extremes, as days above 35oC (and upwards of 45oC) are increasingly common. Many industries require staff to engage in outdoor work, often involving high levels of physical intensity. Compliance with occupational heat guidelines is reportedly low. Adoption of health protective strategies requires accurate risk perception. Australian heat exposed workers report discomfort when working in hot weather, yet little is known about their personal risk assessment.

Methods

Heat exposed outdoor workers across Australia (n = 112) completed pre-study surveys about their personal heat tolerance and completed daily heat diaries (n = 3421) to record their thermal comfort, heat symptoms and productivity, whilst on-site maximum temperatures and humidity were monitored.

Results

Daily maximum temperatures ranged from 18-43oC, and WBGT levels in parts of Australia exceed hazardous levels most days throughout summer. Significant overestimation of thermal tolerance was reported, as “feeling too hot to keep working” and emergence of symptoms occurred up to ten degrees lower than expected.

Conclusions

Heat exposed workers consistently over-estimate their thermotolerance and capacity to perform physically intensive work. Increasing frequency and intensity of heat waves escalates future risks of health harm and deaths among heat exposed workers. Health protection necessitates active health education/ health promotion campaigns to better align perceived and actual health risks. Main messages: Global warming presents intensifying health and productivity threats. Widespread lack of recognition of personal health threats suggests a critical need for heath education/promotion to increase heat guideline compliance

Key messages

Increasing frequency and intensity of heat waves from climate change escalates future risks of health harm and deaths among heat exposed workers who over-estimate their thermotolerance. Widespread lack of recognition of personal heat exposure threats suggests a critical need for health education/promotion to increase heat guidelines compliance.

Impact of Axial Eye Size on Retinal Microvasculature Density in the Macular Region

Mechanical tissue stresses are important contributors to the increased risk of sight-threatening pathology in larger, more myopic eyes. The contribution of altered ocular vasculature to the development of this pathology is less well defined. The current study investigated the impact of eye size on the superficial vasculature of the macula. Subjects (n = 104) aged 18–50, with no history of ocular or vascular disease, or myopia control, were recruited from university staff and student populations in Australia and Hong Kong. Refractive error, ocular size, retinal morphology and vascular morphology were quantified through open field autorefraction, ocular biometry and ocular coherence tomography angiography. Morphology of the superficial retinal capillary plexus was assessed over a 3 × 3 mm fovea-centred area. Perfusion area and vessel length densities were analysed relative to axial eye length and retinal thickness. A significant inverse association was found between axial length and vascular density measures (perfusion area density r² = 0.186, p < 0.001; and vessel length density r² = 0.102, p = 0.001). Perfusion area and vessel length densities were reduced by 5.8% (p = 0.001) in the longest, relative to the shortest, eyes. The aggregated ganglion cell layer inner plexiform layer thickness was also inversely associated with eye size (r² = 0.083, p = 0.003), and reduced, by 8.1% (p < 0.001), in the longest eyes. An inverse association of eye size and superficial retinal vasculature density, that is not simply explained by retinal expansion or image magnification factors, was confirmed. These data support the hypothesis that ongoing metabolic challenges may underlie the development of myopia-related and -associated pathology in larger eyes.

A qualitative exploration of the content and face validity of preference-based measures within the context of dementia

BACKGROUND

Assessing the cost-effectiveness of interventions for people with dementia, based on cost per quality-adjusted life years (QALYs) gained, requires that the measures used to derive QALYs are preference-based whilst also being valid, feasible to use, comprehensible and acceptable for people with dementia. The aim of this study was to assess the content and face validity of six preference-based measures (PBMs) within the context of dementia.

METHODS

Qualitative focus groups and interviews were conducted with community-dwelling individuals with mild dementia and carers of people with dementia. After exploring participants' understanding of 'quality of life' (QoL), six PBMs were assessed for content and face validity: two measures assessing health-related QoL (EQ-5D-5L and AQoL-8D); two covering broader aspects of capability wellbeing and social care-related QoL (ICECAP-O and ASCOT); and two dementia-specific QoL measures (DEMQOL-U and AD-5D). A random mix of one health-related QoL measure, one wellbeing measure, and one dementia-specific measure was explored in each session. All sessions were audiotaped and transcribed verbatim. Data were analysed thematically.

RESULTS

Nine individuals with mild dementia and 17 carers of people with dementia participated across 4 focus groups and 10 interviews. Participants perceived 9 broad QoL domains as relevant to them: Activity, Autonomy, Cognition, Communication, Coping, Emotions, End-of-Life, Physical Functioning, and Relationships. These domains had limited overlap with the content of the six PBMs. Assessment of face validity was summarized into eight themes: (1) ambiguous questions, (2) double -barrelled questions, (3) difficult/abstract questions, (4) judgemental/confronting questions, (5) lack of relevance and comprehensiveness, (6) response options, (7) layout/format and (8) proxy-response. There was no clear preference for one of the six measures explored; participants identified advantages and disadvantages across all measures. Although particularly designed for individuals with dementia, dementia-specific QoL measures were not always favoured over non-specific measures.

CONCLUSION

Given the shortcomings of PBMs identified in this study, further empirical comparative analyses are necessary to guide the selection of PBMs for future dementia research.

The Association between Health Literacy and Self-Rated Health Amongst Australian University Students

Health literacy is the capacity to understand, access, and effectively utilize health information and healthcare to make informed health decisions. This cross-sectional study uses the multi-dimensional Health Literacy Questionnaire (HLQ) to investigate associations between demographic characteristics, self-rated health and health literacy among students (n = 932) in two Australian universities. We used Pearson's chi-square to determine differences in self-rated health between demographic groups, Cohen's defect Sizeto measure differences in HLQ scale scores between demographic groups, and logistic regression to determine associations between HLQ scores and self-rated health. A clear association was found between self-rated health and health literacy: as health literacy increased, so did self-rated health. Findings also demonstrate lower health literacy for culturally and linguistically diverse students, and those studying Arts compared to Health degrees. Lower self-rated health was correlated with HLQ scales including being less active in managing one's own health, having less social support for one's health, possessing insufficient health information and lower confidence in navigating the healthcare system. This study provides a comprehensive picture of potentially vulnerable students and identifies strategies for supporting their health endeavors while studying at university.

Defining discharge-readiness from subacute care from all stakeholders' perspectives: a systematic review

Purpose: Research to date has focused on clinicians' views on patients' discharge readiness from acute hospital settings.This study aims to synthesise the literature on discharge readiness from sub-acute (rehabilitation) hospital settings from all stakeholders' perspectives.Methods: Electronic databases (MEDLINE, CINAHL, Ageline, AMED and Global Health) were systematically searched for post-2000 publications on discharge readiness of adult inpatients in sub-acute settings. After screening, quantitative and qualitative studies were assessed for bias using the Downs and Black checklist and McMaster critical assessment tool respectively, and narrative analysis conducted.Results: From the 3516 papers identified, 23 were included in the review. Overall quality of articles was rated as adequate. Narrative synthesis identified three main themes: the importance of functional outcomes; confounding factors impact on discharge destination and length of stay and barriers and facilitators to discharge.Conclusion: Despite limited literature defining sub-acute patients' discharge-readiness from all stakeholders' perspectives, synthesis of available findings identified major themes for consideration when determining when a patient is ready to leave hospital. Limitations include the heterogeneity of the studies located impacted on data extraction and quality appraisal.IMPLICATIONS FOR REHABILITATIONDischarging patients from hospital is complex, discharge too early may lead to poor medical outcomes or readmission, while discharge too late may increase the risk of hospital-based adverse events.Multiple factors need to be considered when considering the discharge readiness of an inpatient.Ensuring adequate social support is key to maximising transition from hospital to home.Combining the use of functional outcome measures with clinical decision-making allows for quantifying readiness for discharge.

Implementing empowerment-based Lay Health Worker programs: a preliminary study

Lay Health Worker (LHW) programs have been shown to be effective in engaging community members in health promotion. While successful LHW program implementation requires an understanding of factors influencing program effectiveness, evidence informing such understanding is lacking for empowerment and ecological theory-based LHW programs. This descriptive study explores how enablers and barriers, identified from LHW literature apply (from the LHWs' perspective) in the context of implementing an empowerment and ecological theory-based LHW model in Melbourne, Victoria. A qualitative case study was carried out. Data were collected from participating LHWs (n = 11) via anonymized online activity logs (n = 7) and semi-structured interviews (n = 7). Deductive-inductive thematic analysis was guided by five a priori themes identified from the literature: community relationships; intrinsic traits, values and motivations; capacity building; program design; and work conditions. Data supported the enablers and barriers to program effectiveness and implementation reported by previous research. Subthemes identified the importance of the LHW bridging role; the empowerment model; integrating the program; and program inclusiveness. This research contributes to the growing practice literature regarding how to effectively implement diverse LHW models in diverse settings. It also contributes to social ecological and complex systems-based health promotion practice evidence in suggesting LHWs to be potentially useful elements which may add to the effectiveness of ecologically based health promotion interventions.

Factors influencing sweet drink consumption among preschool-age children: A qualitative analysis

ISSUE ADDRESSED

Consumption of high sugar foods and drinks are key risk factors for childhood obesity and dental decay. Sweet drinks are the single greatest contributor to the free sugars consumed by Australian children. Little is known about the factors influencing consumption of sweet drinks, particularly among preschool-age children.

METHODS

Focus groups and semi-structured interviews conducted with parents and grandparents (n = 25) residing in different socio-economic areas across metropolitan and regional Victoria, Australia. Thematic analysis identified the factors influencing sweet drink consumption, which were then aligned with the socio-ecological model.

RESULTS

At an individual level, health knowledge, health beliefs, and parenting skills and confidence influenced drink choices. At the social level, peer and family influence, and social and cultural norms emerged as influential. At the environmental level, sweet drink availability, targeted marketing, drink prices and settings-based policies influenced drink choices. Strategies identified by participants to support healthier drink choices included health education at the individual level; positive role modelling at the social level; and restricting unhealthy marketing, improved access to water, decreased availability of sweet drinks and price modification at the environmental level.

CONCLUSION

Sweet drink consumption among preschool-age children is influenced by multiple factors across all domains of the socio-ecological model. Parents and grandparents are calling for education, healthy environments and supportive policies. SO WHAT?: In contrast to common rhetoric, children's sweet drink consumption is often influenced by factors beyond parental control. A multi-component strategy is required to support parents and grandparents in their efforts to make healthy choices for their children.

Barriers to first time parent groups: A qualitative descriptive study

First-time parents' groups are offered to new parents in Australia to support their transition to parenthood. Not all parents avail of the service, some cease attendance, and fathers are under-represented. In the present descriptive, qualitative study, we examined first-time mothers' perspectives on the barriers to parental participation in the groups. Semi-structured interviews were conducted with a sample of eight first-time mothers in a regional city in Victoria, Australia. Interviews revealed groups were perceived as sites strongly reinforcing traditional social norms of parenting. From this central theme, six gendered subthemes emerged as barriers to attendance. Barriers to mothers included non-normative mothering narratives, such as experiencing stillbirth or having a disabled child, perceived dissonance in parenting ethos, and group size. Barriers to fathers, as perceived by mothers, included groups as female spaces, dads as a minority, and female gatekeeping. A multi-faceted approach is required to change the common perception that groups are for mothers only. Groups need to be more inclusive of different parenting experiences and philosophies. Segregated groups might better address the needs of both parents. Further research is required to capture fathers' perspectives.

The Three-item ALERT-B Questionnaire Provides a Validated Screening Tool to Detect Chronic Gastrointestinal Symptoms after Pelvic Radiotherapy in Cancer Survivors

AIMS

Although pelvic radiotherapy is an effective treatment for various malignancies, around half of patients develop significant gastrointestinal problems. These symptoms often remain undetected, despite the existence of effective treatments. This study developed and refined a simple screening tool to detect common gastrointestinal symptoms in outpatient clinics. These symptoms have a significant effect on quality of life. This tool will increase detection rates and so enable access to specialist gastroenterologists, which will in turn lead to improved symptom control and quality of life after treatment.

MATERIALS AND METHODS

A literature review and expert consensus meeting identified four items for the ALERT-B (Assessment of Late Effects of RadioTherapy - Bowel) screening tool. ALERT-B was face tested for its usability and acceptability using cognitive interviews with 12 patients experiencing late gastrointestinal symptoms after pelvic radiotherapy. Thematic analysis and probe category were used to analyse interview transcripts. Interview data were presented to a group of experts to agree on the final content and format of the tool. ALERT-B was assessed for reliability and tested for validity against the Gastrointestinal Symptom Rating Scale in a clinical study (EAGLE).

RESULTS

Overall, the tool was found to be acceptable in terms of wording, response format and completion time. Participant-reported experiences, including lifestyle modifications and the psychological effect of the symptoms, led to further modifications of the tool. The refined tool includes three questions covering rectal bleeding, incontinence, nocturnal bowel movements and impact on quality of life, including mood, relationships and socialising. ALERT-B was successfully validated against the Gastrointestinal Symptom Rating Scale in the EAGLE study with the tool shown broadly to be internally consistent (Cronbach's α = 0.61 and all item-subscale correlation [Spearman] coefficients are > 0.6).

CONCLUSION

The ALERT-B screening tool can be used in clinical practice to improve post-treatment supportive care by triggering the clinical assessment of patients suitable for referral to a gastroenterologist.

Patient perspectives on a personally controlled electronic health record used in regional Australia

BACKGROUND

Personally controlled electronic health records (PCEHRs) are being implemented throughout Australia; yet few studies have investigated patients' experiences of using a PCEHR.

AIM

To explore patients' experiences and perspectives of using a locally developed PCEHR implemented in an Australian health service.

METHOD

Twelve patients completed individual semi-structured telephone interviews, which underwent inductive analysis.

RESULTS

Participants described two main interdependent advantages of PCEHRs: improved quality of healthcare through better information sharing and enhanced patient capacity for self-management. To realise these advantages, widespread acceptance and use of PCEHRs by healthcare providers is required, and PCEHRs need to be simple to use and accessible.

CONCLUSION

PCEHRs can produce tangible benefits for patients. However, maximum benefits will be realised when PCEHRs contain a complete collection of relevant health information and are carefully designed for easy use.

Evaluation of CD46 re-targeted adenoviral vectors for clinical ovarian cancer intraperitoneal therapy

Ovarian cancer accounts for >140 000 deaths globally each year. Typically, disease is asymptomatic until an advanced, incurable stage. Although response to cytotoxic chemotherapy is frequently observed, resistance to conventional platinum-based therapies develop rapidly. Improved treatments are therefore urgently required. Virotherapy offers great potential for ovarian cancer, where the application of local, intraperitoneal delivery circumvents some of the limitations of intravenous strategies. To develop effective, adenovirus (Ad)-based platforms for ovarian cancer, we profiled the fluid and cellular components of patient ascites for factors known to influence adenoviral transduction. Levels of factor X (FX) and neutralizing antibodies (nAbs) in ascitic fluid were quantified and tumor cells were assessed for the expression of coxsackie virus and adenovirus receptor (CAR) and CD46. We show that clinical ascites contains significant levels of FX but consistently high CD46 expression. We therefore evaluated in vitro the relative transduction of epithelial ovarian cancers (EOCs) by Ad5 (via CAR) and Ad5 pseudotyped with the fiber of Ad35 (Ad5T*F35++) via CD46. Ad5T*F35++ achieved significantly increased transduction in comparison to Ad5 (P<0.001), independent of FX and nAb levels. We therefore propose selective transduction of CD46 over-expressing EOCs using re-targeted, Ad35-pseudotyped Ad vectors may represent a promising virotherapy for ovarian cancer.

Service providers' experiences and needs in working with refugees in the Geelong region: a qualitative study

Service providers in Geelong, one of the priority locations for the resettlement of refugees in regional Australia, were interviewed to explore their perceptions of the health and wellbeing needs of refugees, and the capacity of service providers in a regional area to meet these. In all, 22 interviews were conducted with health and human service professionals in a range of organisations offering refugee-specific services, culturally and linguistically diverse (CALD) services in general, and services to the wider community, including refugees. The findings revealed that a more coordinated approach would increase the effectiveness of existing services; however, the various needs of refugees were more than could be met by organisations in the region at current resource levels. More staff and interpreting services were required, as well as professional development for staff who have had limited experience in working with refugees. It should not be assumed that service needs for refugees resettled in regional Australia will be the same as those of refugees resettled in capital cities. Some services provided in Melbourne were not available in Geelong, and there were services not currently provided to refugees that may be critical in facilitating resettlement in regional and rural Australia.

Playing Active Video Games may not develop movement skills: An intervention trial

BACKGROUND

To investigate the impact of playing sports Active Video Games on children's actual and perceived object control skills.

METHODS

Intervention children played Active Video Games for 6 weeks (1 h/week) in 2012. The Test of Gross Motor Development-2 assessed object control skill. The Pictorial Scale of Perceived Movement Skill Competence assessed perceived object control skill. Repeated measurements of object control and perceived object control were analysed for the whole sample, using linear mixed models, which included fixed effects for group (intervention or control) and time (pre and post) and their interaction. The first model adjusted for sex only and the second model also adjusted for age, and prior ball sports experience (yes/no). Seven mixed-gender focus discussions were conducted with intervention children after programme completion.

RESULTS

Ninety-five Australian children (55% girls; 43% intervention group) aged 4 to 8 years (M 6.2, SD 0.95) participated. Object control skill improved over time (p = 0.006) but there was no significant difference (p = 0.913) between groups in improvement (predicted means: control 31.80 to 33.53, SED = 0.748; intervention 30.33 to 31.83, SED = 0.835). A similar result held for the second model. Similarly the intervention did not change perceived object control in Model 1 (predicted means: control: 19.08 to 18.68, SED = 0.362; intervention 18.67 to 18.88, SED = 0.406) or Model 2. Children found the intervention enjoyable, but most did not perceive direct equivalence between Active Video Games and 'real life' activities.

CONCLUSIONS

Whilst Active Video Game play may help introduce children to sport, this amount of time playing is unlikely to build skill.

Utilisation of beds on the general medical unit by 'non-acute medical' patients: a retrospective study of incidence and cost in two Tasmanian regional medical hospital units

BACKGROUND

Demand for healthcare services threatens to overwhelm the Australian healthcare system. Public hospitals have the largest component of expenditure growth and as such represent the largest opportunity for efficiency gains. Utilisation of inpatient hospital beds and in particular those on general medical units has not been studied in Australia.

AIM

To undertake a retrospective patient medical record review of 200 sequential admissions to the medical wards in two regional Tasmanian hospitals to determine the incidence of non-acute medical patient admission to the medical unit, and the subsequent days in hospital that were not required for medical reasons. The cost of these days was estimated.

RESULTS

Sixteen patient admissions (8%) could not be justified on medical grounds. Forty-eight (24%) patient admissions had at least one day hospital day that could not be justified on medical grounds. Of the 1438 total bed days, 475 (33%) were for non-medical reasons. The estimated cost of those non-medical bed days for this cohort was $764 800.

CONCLUSIONS

The incidence of non-acute medical admissions and non-acute medical bed days to the medical unit and associated cost was significant. Further research is needed to design alternative care provision for such patients particularly in regional Australia. The potential savings to the Australian healthcare system could be significant.

Using information and communication technologies to consult with patients in Victorian primary care: the views of general practitioners

Information and communication technologies such as email, text messaging and video messaging are commonly used by the general population. However, international research has shown that they are not used routinely by GPs to communicate or consult with patients. Investigating Victorian GPs' perceptions of doing so is timely given Australia's new National Broadband Network, which may facilitate web-based modes of doctor-patient interaction. This study therefore aimed to explore Victorian GPs' experiences of, and attitudes toward, using information and communication technologies to consult with patients. Qualitative telephone interviews were carried out with a maximum variation sample of 36GPs from across Victoria. GPs reported a range of perspectives on using new consultation technologies within their practice. Common concerns included medico-legal and remuneration issues and perceived patient information technology literacy. Policy makers should incorporate GPs' perspectives into primary care service delivery planning to promote the effective use of information and communication technologies in improving accessibility and quality of general practice care.

Training in clinical oncology: results of the Royal College of Radiologists' survey of new consultants

AIMS

To seek the views of consultants appointed less than 2 years ago on the appropriateness of their training in fitting them to carry out their present posts, the FRCR examination, experience of research and the prevalence and value of out of programme experience and acting up as a consultant.

MATERIALS AND METHODS

All the consultants identified from the Royal College of Radiologists' database as having been appointed to a consultant post in the last 2 years were emailed inviting them to take part in a web-based survey.

RESULTS

The response rate was 60% (32 of 53 consultants). Ninety-four per cent agreed or strongly agreed that training had equipped them for clinical work as a consultant, but only 44% agreed or strongly agreed that training had equipped them to fulfil the management roles. Free text answers stressed the importance of management skills, getting involved with trial set-up and producing publications early in their career. Ninety-four per cent agreed or strongly agreed that they had adequate opportunity to develop skills in systemic therapy and radiotherapy planning, but only 56% thought this was the case for intensity-modulated radiotherapy and image-guided radiotherapy. Although 87% agreed or strongly agreed they had sufficient opportunity to develop teaching skills, this was only the case in 62% with regard to research skills. They published a median number of three papers in peer-reviewed journals. Twenty-five per cent of respondents studied for research degrees; 69% of consultants had undertaken out of programme experience and 50% had acted up as a consultant and these were generally found to be valuable experiences. There was strong support for the FRCR examination.

CONCLUSIONS

Consultants appointed in the last 2 years are generally satisfied with their training. Training in intensity-modulated radiotherapy and image-guided radiotherapy should be improved and the advanced specialist training requires reviewing to better fit consultants for subspecialisation, management and research.

The place of information and communication technology-mediated consultations in primary care: GPs' perspectives

BACKGROUND

New information and communication technologies such as email and text messaging have been shown to be useful in some aspects of primary care service delivery. Little is known about Scottish GPs' attitudes towards the adoption of these technologies as routine consultation tools.

OBJECTIVES

To explore GPs' perceptions of the potential place of new non-face-to-face consultation technologies in the routine delivery of primary care; to explore GPs' perceived barriers to the introduction of these technologies and to identify the processes by which GPs feel that new consultation technologies could be incorporated into routine primary care.

METHODS

Qualitative interview study: 20 in-depth semi-structured interviews carried out with maximum variation sample of GPs across Scotland.

RESULTS

Whilst the face-to-face consultation was seen as central to much of the clinical and diagnostic work of primary care, many GPs were conditionally willing to consider using new technologies in the future, particularly to carry out administrative or less complex tasks and therefore maximize practice efficiency and patient convenience. Key considerations were access to appropriate training, IT support and medico-legal guidance.

CONCLUSIONS

GPs are conditionally willing to use new consultation media if clinically appropriate and if medico-legal and technical support is available.