Home symptom management training programme: carer evaluation

OBJECTIVES

Most people say if they had a terminal illness, they would prefer to be cared for at home and, if possible, to die there. Often this is not possible without a carer to assist with on-going practical care and symptom management. If breakthrough symptoms are not treated in a timely manner, symptoms can escalate quickly causing increased suffering resulting in unwanted hospital transfers. Many carers report feeling motivated but uneducated for the task of medicine management, especially if it involves preparation and/or administration of subcutaneous medicines This study assesses the impact of an education and resource package, caring@home, on carers' confidence, knowledge, and skills in managing palliative symptoms at home using subcutaneous medicines.

METHODS

Nurses trained volunteer carers on the use of the package. Carers were invited to complete a 10 min written evaluation survey and to consider consenting to a 30 min semistructure phone interview.

RESULTS

Fifty carers returned surveys and 12 were interviewed. Most carers agreed or strongly agreed that the package provided them with the necessary knowledge, skills and confidence to safely and confidently manage breakthrough symptoms using subcutaneous medicines, further, they would recommend the package to others. Interview analysis revealed three main themes: (1) hesitation and motivation to adopt expanded carer role; (2) the importance of a layered approach to support; and (3) avoiding perceived unnecessary contact with nurses.

CONCLUSION

The programme can be used by clinical services to empower carers to help enable a person to be cared for, and to die at home.

Source attribution of campylobacteriosis in Australia, 2017-2019

Campylobacter jejuni and Campylobacter coli infections are the leading cause of foodborne gastroenteritis in high-income countries. Campylobacter colonizes a variety of warm-blooded hosts that are reservoirs for human campylobacteriosis. The proportions of Australian cases attributable to different animal reservoirs are unknown but can be estimated by comparing the frequency of different sequence types in cases and reservoirs. Campylobacter isolates were obtained from notified human cases and raw meat and offal from the major livestock in Australia between 2017 and 2019. Isolates were typed using multi-locus sequence genotyping. We used Bayesian source attribution models including the asymmetric island model, the modified Hald model, and their generalizations. Some models included an "unsampled" source to estimate the proportion of cases attributable to wild, feral, or domestic animal reservoirs not sampled in our study. Model fits were compared using the Watanabe-Akaike information criterion. We included 612 food and 710 human case isolates. The best fitting models attributed >80% of Campylobacter cases to chickens, with a greater proportion of C. coli (>84%) than C. jejuni (>77%). The best fitting model that included an unsampled source attributed 14% (95% credible interval [CrI]: 0.3%-32%) to the unsampled source and only 2% to ruminants (95% CrI: 0.3%-12%) and 2% to pigs (95% CrI: 0.2%-11%) The best fitting model that did not include an unsampled source attributed 12% to ruminants (95% CrI: 1.3%-33%) and 6% to pigs (95% CrI: 1.1%-19%). Chickens were the leading source of human Campylobacter infections in Australia in 2017-2019 and should remain the focus of interventions to reduce burden.

Harnessing citizen science in health promotion: perspectives of policy and practice stakeholders in Australia

Citizen science is rapidly gaining momentum as a means of involving members of the public in research and decision-making in disease prevention and health promotion. However, citizen science projects have predominantly been led by academic researchers and there is limited understanding of how to support the application of citizen science approaches in policy and practice settings. This study aimed to understand the perceptions, motivations and early experiences of applying citizen science approaches in policy and practice settings. Semi-structured interviews were conducted with policy and practice stakeholders who were leading citizen science projects (project partners, n = 7), and their implementation partners (project implementers, n = 11). Participants viewed citizen science as an opportunity to access hard-to-reach data and to enhance engagement with community members to support policy and practice change. Barriers and facilitators of citizen science in policy and practice settings included navigating collaborative relationships, team capacity and resources available to deliver projects, recruitment and engagement of citizen scientists and ethical considerations in the design and implementation of citizen science projects. Findings support the feasibility and wider application of citizen science approaches in health promotion and are being used to inform the development of tools and resources to build capacity in these approaches in policy and practice settings.

Food purchasing practices in various retail settings and dietary intake: A cross-sectional survey of Australian adolescents

BACKGROUND/AIMS

Discretionary, energy-dense, nutrient-poor food and drinks are heavily marketed and readily available in retail settings frequented by adolescents. This study examines associations between food purchasing practices in various retail settings and dietary intake among Australian adolescents.

METHODS

Participants were students in years 8 to 11 (ages 12-17 years) who completed the 2009-10 (n = 13 790), 2012-13 (n = 10 309) or 2018 (n = 9102) National Secondary Students' Diet and Activity (NaSSDA) cross-sectional survey. Multistage stratified random sampling was used. An online survey completed at school assessed self-reported frequency of food purchasing practices in various retail settings and consumption of discretionary food, sugary drinks, fruit and vegetables. Generalised linear regression models examined associations between food purchasing practices and dietary behaviour.

RESULTS

Relative to students who brought lunch from home, those who purchased lunch from school or nearby outlets reported higher intake of discretionary food and sugary drinks and lower fruit intake. Buying lunch from school was also associated with lower vegetable intake. Buying food or drinks on the school commute, outside school grounds during school hours, from supermarket checkouts, and using mobile phone apps were each associated with higher discretionary food and sugary drink intake (all P < .01).

CONCLUSIONS

Purchasing food or drink in various retail settings is associated with higher intake of discretionary food and drink among Australian adolescents, and some purchasing practices appeared to displace fruit and vegetable intake. SO WHAT?: These findings highlight a need to improve the accessibility and promotion of healthier food and drink options in schools and other retail settings.

Against the use of the Strengths and Difficulties Questionnaire for Aboriginal and Torres Strait Islander children aged 2-15 years

OBJECTIVE

The Strengths and Difficulties Questionnaire is a widely used screening tool for emotional and behavioural problems in children. Recent quantitative analyses have raised concerns regarding its structural validity in Aboriginal and Torres Strait Islander communities. This paper aims to extend upon existing findings by analysing the factor structure of both the parent- and teacher-reported Strengths and Difficulties Questionnaire in this population across a broader age range than in previous studies.

METHODS

Participants were the caregivers and teachers of 1624 Aboriginal and Torres Strait Islander children (820 male, 804 female) aged 2-15 years from Waves 2-11 of the Longitudinal Study of Indigenous Children. The majority of children were Aboriginal living in major cities and inner regional areas. Internal consistency was estimated with McDonald's Omega. Exploratory structural equation modelling was conducted to investigate the factor structure of the parent-reported and teacher-reported versions of the Strengths and Difficulties Questionnaire.

RESULTS

Responses from teachers demonstrated higher internal consistency than responses from parents, which was unacceptably low across most age groups. The purported five-factor structure of the Strengths and Difficulties Questionnaire failed to be replicated across both parent- and teacher-reported questionnaires. The results of bifactor and hierarchical exploratory structural equation models also failed to approximate the higher-order summary scales. These results indicate that the Strengths and Difficulties Questionnaire subscales and summary scores do not provide a valid index of emotional and behavioural problems in Aboriginal and Torres Strait Islander children.

CONCLUSION

The Strengths and Difficulties Questionnaire should not be used with Aboriginal and Torres Strait Islander children.

The distribution of registered occupational therapists, physiotherapists, and podiatrists in Australia

BACKGROUND

In Australia, the distribution of occupational therapists, physiotherapists, and podiatrists density (per 10,000 population) by measure of location/rurality, usual resident population, and area-level socioeconomic status has not been described.

OBJECTIVE

To describe the national as well as states-and territories-wide distribution of registered allied health workforce-occupational therapists, physiotherapists, and podiatrists-by measures of rurality and area-level socioeconomic position in Australia.

METHODS

A linked data study that brings together (1) the location of health practitioners' principal place of practice from the Australian Health Practitioner Regulation Agency, (2) a measure of location/rurality-Modified Monash Model (MMM), and (3) an area-level measure of socioeconomic status-Index of Relative Socio-Economic Advantage and Disadvantage (IRSAD). The provider-to-population ratio (i.e., density) of three Australia's allied health workforce (occupational therapists, physiotherapists, and podiatrists) was calculated according to the MMM classifications (i.e., Modified Monash 1-7) and IRSAD quintiles at state and national level.

RESULTS

Nationwide, the density of occupational therapists and physiotherapists was highest in metropolitan areas (Modified Monash 1) and decreased with the increasing levels of the MMM categories. The national density of podiatrists was highest in Modified Monash 3 areas. The density of occupational therapists, physiotherapists, and podiatrists was highest in areas with IRSAD quintile 5 (i.e., the highest socioeconomic position) and decreased with the declining levels of the IRSAD quintiles nationwide. Moreover, there were notable disparities in the density of occupational therapists, physiotherapists, and podiatrists across each state and territory in Australia when stratified by the MMM classifications and IRSAD quintiles.

CONCLUSIONS

There was uneven distribution of registered occupational therapists, physiotherapists, and podiatrists when stratified by measures of location/rurality and area-level socioeconomic status across Australian jurisdictions. The density of these three groups of allied health workforce tended to be more concentrated in metropolitan and most advantaged areas while remote and most disadvantaged areas exhibited less allied health workforce distribution across each state and territory.

The Australian evidence-based clinical practice guideline for attention deficit hyperactivity disorder

OBJECTIVE

The objective of this article was to provide an overview of the development and recommendations from the Australian evidence-based clinical practice guideline for attention deficit hyperactivity disorder (ADHD). The guideline aims to promote accurate and timely identification and diagnosis, and optimal and consistent treatment of ADHD.

METHODS

Development integrated the best available evidence with multidisciplinary clinical expertise and the preferences of those with lived experience, underpinned by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. The 23 guideline development group members included psychiatrists, paediatricians, general practitioners, psychologists, speech pathologists, occupational therapists, educators, Indigenous psychologists, and people with a lived experience; with two independent chairs and a methodologist. Where appropriate, evidence reviews from the National Institute for Health and Care Excellence (NICE) 2018 'Attention Deficit Hyperactivity Disorder: Diagnosis and Management' guideline were updated. Fifty prioritised clinical questions were addressed in 14 systematic reviews (new and updated from NICE 2018) and 28 narrative reviews.

RESULTS

The 113 clinical recommendations apply to young children (5 years and under), children, adolescents and adults. They provide guidance for clinicians on identification, screening, diagnosis, multimodal treatment and support, including pharmacological and non-pharmacological interventions. The guideline and supporting information are available online: https://adhdguideline.aadpa.com.au/.

CONCLUSIONS

The guideline was approved by the National Health and Medical Research Council (NHMRC) of Australia and relevant medical and allied health professional associations. It is anticipated that successful implementation and uptake of the guideline by organisations, health care providers and other professionals will increase delivery of evidence-based treatment and improve health outcomes for the more than 800,000 Australians with ADHD.

Practice, governance, and culture characteristics of lived experience organisations, and evidence of efficacy: A scoping review protocol

BACKGROUND

Mental health policy and service design is increasingly recognizing the importance of the lived experience voice and its inclusion in all aspects of work. Effective inclusion requires a deeper understanding of how best to support lived experience workforce and community members to meaningfully participate in the system.

OBJECTIVES

This scoping review aims to identify key features of organizational practice and governance that facilitate the safe inclusion of lived experience in decision-making and practice within mental health sector contexts. Specifically, the review focuses on mental health organizations devoted to lived experience advocacy or peer support or those in which lived experience membership (paid or voluntary) is central to advocacy and peer support operations.

METHODS

This review protocol was prepared with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and registered with the Open Science Framework. The review will be guided by the Joanna Briggs Institute methodology framework and is being conducted by a multidisciplinary team including lived experience research fellows. It will include published and grey literature, including government reports, organizational online documents, and theses. Included studies will be identified through comprehensive searches of five databases: PsycINFO (Ovid), CINAHL (EBSCO), EMBASE (Ovid), MEDLINE (Ovid), and ProQuest Central. Studies published in English from 2000 onwards will be included. Data extraction will be guided by pre-determined extraction instruments. Results will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews flow chart. Results will be presented in tabular form and narratively synthesized. The planned commencement and completion dates for this review were July 1, 2022 and April 1, 2023.

DISCUSSION

It is anticipated that this scoping review will map the current evidence base underpinning organizational practices in which lived experience workers are involved, specifically in the mental health system. It will also inform future mental health policy and research.

TRIAL REGISTRATION

Registration: Open Science Framework (registered: July 26, 2022; registration DOI: 10.17605/OSF.IO/NB3S5).

The impact of rural nursing and midwifery clinical placements from the perspective of health service staff

OBJECTIVE

To explore the impact of providing nursing and midwifery student placements from the perspective of regional, rural and remote health service staff involved in hosting students.

SETTING

Hospital and health services across regional, rural and remote southern Queensland.

PARTICIPANTS

Thirty-six nursing and midwifery staff working in clinical and/or management roles who were direct clinical supervisors of students or in leadership positions with responsibility for overseeing and supporting clinical placements.

DESIGN

Semi-structured interviews exploring the experiences and perspectives of nursing and midwifery health service staff who support student placements. Data were subject to thematic analysis.

RESULTS

Five key themes were identified as follows: (a) bringing new ideas and perspectives, (b) opportunities for development, (c) supporting the future rural workforce (d) impacts on workload and productivity and (e) strategies for balancing supervision.

CONCLUSION

The results indicate that there are a range of perceived benefits and challenges of providing nursing and midwifery student placements within regional, rural and remote settings. The findings also indicate that there are opportunities to further support rural health services to optimise the positive impacts and mitigate the challenges of providing placements. To do so requires collaboration between health services and education providers to allocate students appropriately to health services and support health service staff.

Radiologist Self-training: a Study of Cancer Detection when Reading Mammograms at Work Clinics or Workshops

Provision of online and remote specialist education and general continued professional education in medicine is a growing field. For radiology specifically, the ability to access web-based platforms that house high resolution medical images, and the high fidelity of simulated activities is increasingly growing due to positive changes in technology. This study investigates the differences in providing a self-directed specialist radiology education system in two modes: at clinics and in-person workshops. 335 Australian radiologists completed 562 readings of mammogram test sets through the web-based interactive BREAST platform with 325 at conference workshops and 237 at their workplaces. They engaged with test sets with each comprising of 60 mammogram cases (20 cancer and 40 normal). Radiologists marked the location of any cancers and had their performance measured via 5 metrics of diagnostic accuracy. Results show that the location of engagement with BREAST did not yield any significant difference in the performances of all radiologists and the same radiologists between two reading modes (P > 0.05). Radiologists who read screening mammograms for BreastScreen Australia performed better when they completed the test sets at designated workshops (P < 0.05), as was also the case for radiologists who read > 100 cases per week (P < 0.05). In contrast, radiologists who read less mammograms frequently recorded better performances in specificity and JAFROC at clinics (P < 0.05). Findings show that remotely accessed online education for specialised training and core skills building in radiology can provide a similar learning opportunity for breast radiologists when compared to on-site dedicated workshops at scientific meetings. For readers with high volumes of mammograms, a workshop setting may provide a superior experience while clinic setting is more helpful to less experienced readers.

Infectious syphilis in women and heterosexual men in major Australian cities: sentinel surveillance data, 2011-2019

OBJECTIVES

To examine changes in the positive infectious syphilis test rate among women and heterosexual men in major Australian cities, and rate differences by social, biomedical, and behavioural determinants of health.

DESIGN, SETTING

Analysis of data extracted from de-identified patient records from 34 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmissible Infections and Blood Borne Viruses (ACCESS).

PARTICIPANTS

First tests during calendar year for women and heterosexual men aged 15 years or more in major cities who attended ACCESS sexual health clinics during 2011-2019.

MAIN OUTCOME MEASURES

Positive infectious syphilis test rate; change in annual positive test rate.

RESULTS

180 of 52 221 tested women (0.34%) and 239 of 36 341 heterosexual men (0.66%) were diagnosed with infectious syphilis. The positive test rate for women was 1.8 (95% confidence interval [CI], 0.9-3.2) per 1000 tests in 2011, 3.0 (95% CI, 2.0-4.2) per 1000 tests in 2019 (change per year: rate ratio [RR], 1.12; 95% CI, 1.01-1.25); for heterosexual men it was 6.1 (95% CI, 3.8-9.2) per 1000 tests in 2011 and 7.6 (95% CI, 5.6-10) per 1000 tests in 2019 (RR, 1.10; 95% CI, 1.03-1.17). In multivariable analyses, the positive test rate was higher for women (adjusted RR [aRR], 1.85; 95% CI, 1.34-2.55) and heterosexual men (aRR, 2.39; 95% CI, 1.53-3.74) in areas of greatest socio-economic disadvantage than for those in areas of least socio-economic disadvantage. It was also higher for Indigenous women (aRR, 2.39; 95% CI, 1.22-4.70) and for women who reported recent injection drug use (aRR, 4.87; 95% CI, 2.18-10.9) than for other women; it was lower for bisexual than heterosexual women (aRR, 0.48; 95% CI, 0.29-0.81) and for women who reported recent sex work (aRR, 0.35; 95% CI, 0.29-0.44). The positive test rate was higher for heterosexual men aged 40-49 years (aRR, 2.11; 95% CI, 1.42-3.12) or more than 50 years (aRR, 2.36; 95% CI, 1.53-3.65) than for those aged 15-29 years.

CONCLUSION

The positive test rate among both urban women and heterosexual men tested was higher in 2019 than in 2011. People who attend reproductive health or alcohol and drug services should be routinely screened for syphilis.

Factors associated with sharing equipment among people who inject drugs: The role of community attachment in harm reduction and health promotion

INTRODUCTION

Sharing injecting equipment is a major route of transmission for blood borne viruses such as hepatitis C and HIV. Although needle and syringe programs are widely available throughout metropolitan Australia, rates of sharing equipment have not significantly changed in recent years. This study aimed to identify factors associated with recent equipment sharing among people who inject drugs in Australia.

METHODS

A paper-based survey was distributed via peer-based organisations between June and November 2018 and was completed by 603 participants. Survey questions addressed recent injecting experiences, equipment sharing, community attachment, stigma and wellbeing. Participants who had recently shared injecting equipment were compared with those who had not shared any equipment using multivariable logistic regression.

RESULTS

Recent equipment sharing was associated with recent heroin use, experiencing any past-year stigma related to injecting drug use, and higher levels of attachment to a community of people who inject drugs. An interaction effect showed increased community attachment was associated with increased odds of sharing equipment among young participants, but with decreased odds of sharing equipment among older participants.

DISCUSSION AND CONCLUSIONS

Community networks of people who inject drugs can play important roles in harm reduction initiatives. While being connected with a community of people who inject drugs increased the odds of sharing injecting equipment, this community connection also increases opportunities for social support, sharing information and mitigating the negative effects of stigma. Collaboratively and meaningfully engaging with communities of people who inject drugs has the potential to increase the reach and effectiveness of health promotion services.

Immigrants experience oral health care inequity: findings from Australia's National Study of Adult Oral Health

BACKGROUND

Oral health service utilization contributes to positive oral health and indicates realised access to services. The study aimed to describe patterns of oral health service use among overseas-born and Australian-born populations and assess equity in access to services.

METHODS

The study used data from Australia's National Study of Adult Oral Health 2017-2018 and was guided by the Aday and Andersen framework of access to health and Australia's National Oral Health Plan. Descriptive analyses of service use by perceived need, enabling and predisposing factors were compared between four groups: Australian-born and overseas-born who mainly speak English and Australian-born and overseas-born who mainly speak a language other than English.

RESULTS

Overseas-born who mainly speak a language other than English experienced greater oral health care inequity, largely driven by financial difficulty (avoided care due to cost: 42% vs 27%-28%; avoided/delayed visiting due to cost: 48% vs. 37%-38%; cost prevented treatment: 32% vs. 18%-24%). The most favourable visiting patterns were among the Australian-born population who speak a language other than English.

CONCLUSIONS

The study shows clear inequity experienced among immigrants in accessibility as measured through indicators of oral health care utilization and factors related to inequity, such as the ability to pay for services.

Knowledge of Australia's My Health Record and factors associated with opting out: Results from a national survey of the Australian general population and communities affected by HIV and sexually transmissible infections

My Health Record is Australia's national, digital, personal health record system. All Australians have a record in the system unless they choose to opt out of it. Concerns about privacy, security and unwanted sharing of data, particularly in marginalised populations, may impede its use. We conducted a national, online survey of Australians' attitudes to digital health in April-June 2020. The sample (N = 2,240) was recruited from the general population and four priority populations affected by HIV and other sexually transmissible infections: gay and bisexual men, people living with HIV, sex workers, and trans and gender diverse people. This analysis assesses factors associated with greater knowledge of My Health Record and the likelihood of opting out of the system. Due to increased concerns about data privacy and misuse, we hypothesised that priority population members would know more about and be more likely to opt out of the system. We found that most of the sample (71.2%) knew little about My Health Record and 29.4% had opted out of the system. Greater knowledge of My Health Record was associated with younger age, having a university degree, having one or more health conditions, and being trans or gender diverse. Being a student, unemployed, receiving government benefits, or having poor self-reported health, were associated with less knowledge. Opting out of My Health Record was associated with having a university degree, one or more health conditions, and being a priority population member. The likelihood of opting out was lower among people born overseas, residents of Queensland, and people who were students, unemployed, or receiving government benefits. We recommend additional investment in community-based education to address people's concerns about My Health Record and support people to use the system without compromising their health care, privacy, or security. Opting out may be a legitimate choice for people who perceive more risks than benefits from the system.

Renal impairment associated with tenofovir disoproxil fumarate for antiretroviral therapy and HIV pre-exposure prophylaxis: An observational cohort study

BACKGROUND

Tenofovir disoproxil fumarate (TDF) is associated with adverse renal outcomes when prescribed for HIV infection. There are few data concerning real-world renal outcomes amongst patients prescribed TDF for pre-exposure prophylaxis (PrEP).

METHODS AND FINDINGS

Data were extracted from 52 sexual health clinics across Australia from 2009-2019. All patients prescribed TDF-containing antiretroviral therapy and PrEP were included. Rates of renal impairment (a fall in eGFR to <60 ml/min/1·73m2) were calculated for people living with HIV (PLWHIV) prescribed TDF and HIV negative PrEP-users. Risk factors were assessed using Cox-proportional hazards models. Sensitivity analysis of risk using 1:1 propensity-score matching to adjust for potential imbalance in HIV and PrEP cohorts was conducted. 5,973 patients on PrEP and 1,973 PLWHIV were included. There were 39 (0.7%) instances of renal impairment in the PrEP group and 81 (4.1%) in the PLWHIV cohort (hazard ratio [HR]:0.35 95% confidence interval [CI]: 0.22-0.56). Rates of renal impairment were 4.01/1000 person-years (95%CI:2.93-5.48) in the PrEP cohort and 16.18/1000 person-years (95%CI:13.01-20.11) in the PLWHIV cohort (p<0.001). Predictors of renal impairment were: older age (40-49 years (HR:5.09 95%CI: 2.12-12.17) and 50-82 years (HR:13.69 95%CI: 5.92-31.67) (compared with 30-39 years) and baseline eGFR<90ml/min (HR:61.19 95%CI: 19.27-194.30). After adjusting for age and baseline eGFR the rate of renal impairment remained lower in the PrEP cohort (aHR:0.62 95%CI: 0.40-0.94, p = 0.023). In propensity-matched analysis using 1,622 patients per cohort the risk of renal impairment remained higher in the PLWHIV cohort (log-rank p = 0.001).

CONCLUSION

Patients prescribed TDF-based PrEP had lower rates of renal impairment than patients prescribed TDF for HIV infection. In propensity analysis, after matching for some risk factors, rates of renal impairment remained higher amongst patients with HIV.

Engaging Stigmatised Communities in Australia with Digital Health Systems: Towards Data Justice in Public Health

Introduction

In 2018, following government policy changes to Australia's national electronic health record system, 'My Health Record', consumer advocates-including organisations representing people living with HIV, people who use drugs and sex workers-raised concerns about privacy and data security. Responding to these controversies, this study explores the practical, ethical and political complexities of engaging stigmatised communities with digital health systems.

Methods

We conducted 16 qualitative semi-structured interviews in 2020 with key informants representing communities who experience stigma, discrimination and marginalisation in Australia. These communities included people living with HIV, sex workers, people who inject drugs, gay and bisexual men and transgender and gender diverse people. We conducted a reflexive thematic analysis.

Results

Key informants were sceptical of proposed benefits of electronic health records for their communities, and concerned about privacy risks and the potential for discrimination. Meaningful consultation, consent mechanisms and tackling structural stigma were raised as solutions for engaging communities.

Conclusions

Although communities could benefit from being included in digital health systems, significant cultural, legal and social reforms from government were believed to be necessary to build trust in digital health systems. We argue that these forms of data justice are necessary for effective future systems.

Policy Implications

Engaging stigmatised communities-including in relation to gender, sexuality, sex work, drug use, HIV-requires a commitment to data justice. The design and implementation of digital health systems requires investment in ongoing and meaningful consultation with communities and representative organisations.

Temporal trends in, and associations of, early-career general practitioner prescriptions of second-line Type 2 Diabetes medications, 2010-2018

INTRODUCTION

Second-line pharmacotherapy for Type 2 Diabetes Mellitus ('diabetes') is necessary for optimal glycaemic control and preventing longer-term complications. We aimed to describe temporal trends in, and associations of, Australian general practitioner (GP) registrars' prescription, and initiation, of 'new' second-line oral agents (dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 agonists) compared to sulphonylureas.

MATERIALS AND METHODS

A longitudinal analysis (2010-2018) of data from the Registrar Clinical Encounters in Training project. Analysis included any diabetes problem/diagnosis that involved prescription of sulphonylureas or 'new' oral agents. Simple and multiple logistic regression models were fitted within the generalised estimating equations framework.

RESULTS

2333 registrars recorded 6064 diabetes problems/diagnoses (1.4%). 835 problems/diagnoses involved sulphonylurea or 'new' medication prescription. Of these, 61.0% [95% CI:57.4-64.4] involved 'new' medication prescription. 230 problems/diagnoses involved sulphonylurea or 'new' medication initiation, with 77% [95%CI:70.8-82.1] involving a 'new' medication. There was a significant 52% per year increase in prescribing (OR = 1.52[95% CI:1.38-1.68],p<0.001), and a 77% per (two-to-three-year) time-interval increase in initiation (OR = 1.77,[95% CI:1.30-2.43],p = <0.001) of 'new' medications compared to sulphonylureas. 'New' medications were prescribed less for non-English-speaking patients. There was some regional variation in prescribing.

CONCLUSION

Registrar uptake of 'new' oral agents compared to sulphonylureas has increased rapidly.

Diagnostic delay of sarcoidosis: Protocol for an integrated systematic review

INTRODUCTION

Sarcoidosis is a rare systemic inflammatory granulomatous disease of unknown cause. It can manifest in any organ. The incidence of sarcoidosis varies across countries, and by ethnicity and gender. Delays in the diagnosis of sarcoidosis can lead to extension of the disease and organ impairment. Diagnosis delay is attributed in part to the lack of a single diagnostic test or unified commonly used diagnostic criteria, and to the diversity of disease manifestations and symptom load. There is a paucity of evidence examining the determinants of diagnostic delay in sarcoidosis and the experiences of people with sarcoidosis related to delayed diagnosis. We aim to systematically review available evidence about diagnostic delay in sarcoidosis to elucidate the factors associated with diagnostic delay for this disease in different contexts and settings, and the consequences for people with sarcoidosis.

METHODS AND ANALYSIS

A systematic search of the literature will be conducted using PubMed/Medline, Scopus, and ProQuest databases, and sources of grey literature, up to 25th of May 2022, with no limitations on publication date. We will include all study types (qualitative, quantitative, and mixed methods) except review articles, examining diagnostic delay, incorrect diagnosis, missed diagnosis or slow diagnosis of all types of sarcoidosis across all age groups. We will also examine evidence of patients' experiences associated with diagnostic delay. Only studies in English, German and Indonesian will be included. The outcomes we examine will be diagnostic delay time, patients' experiences, and factors associated with diagnostic delay in sarcoidosis. Two people will independently screen the titles and abstracts of search results, and then the remaining full-text documents against the inclusion criteria. Disagreements will be resolved with a third reviewer until consensus is reached. Selected studies will be appraised using the Mixed Methods Appraisal Tool (MMAT). A meta-analysis and subgroup analyses of quantitative data will be conducted. Meta-aggregation methods will be used to analyse qualitative data. If there is insufficient data for these analyses, a narrative synthesis will be conducted.

DISCUSSION

This review will provide systematic and integrated evidence on the diagnostic delay, associated factors, and experiences of diagnosis delay among people with all types of sarcoidosis. This knowledge may shed light on ways to improve diagnosis delays in diagnosis across different subpopulations, and with different disease presentations.

ETHICS AND DISSEMINATION

Ethical approval will not be required as no human recruitment or participation will be involved. Findings of the study will be disseminated through publications in peer-reviewed journals, conferences, and symposia.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42022307236. URL of the PROSPERO registration: https://www.crd.york.ac.uk/PROSPEROFILES/307236_PROTOCOL_20220127.pdf.

Healthcare expenditure and its socio-demographic and clinical predictors in Australians with poorly controlled asthma

INTRODUCTION

Asthma has substantial and increasing health and economic burden worldwide. This study aimed to estimate healthcare expenditure and determine the factors that increase expenditure in Australians with poorly controlled asthma.

METHODS

Individuals ≥18 years of age with poorly controlled asthma, as determined by a score ≥1.5 on the Asthma Control Questionnaire, were included in the study. Healthcare utilization costs from medical services and medications were estimated over an average follow-up of 12 months from administratively linked data: the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. A generalized linear model with gamma distribution and log link was used to predict participants' key baseline characteristics associated with variations in healthcare costs.

RESULTS

A total of 341 participants recruited through community pharmacies were included. The mean (standard deviation, SD) age of participants was 56.6 (SD 17.6) years, and approximately 71% were females. The adjusted average monthly healthcare expenditure per participant was $AU386 (95% CI: 336, 436). On top of the average monthly costs, an incremental expenditure was found for each year increase in age ($AU4; 95% CI: 0.78, 7), being unemployed ($AU201; 95% CI: 91, 311), one unit change in worsening quality of life ($AU35; 95% CI: 9, 61) and being diagnosed with depression and anxiety ($AU171; 95% CI: 36, 306).

CONCLUSIONS

In a cohort of Australian patients, characterized by poor asthma control and co-morbidities individuals impose substantial economic burden in terms of Medicare funded medical services and medications. Programs addressing strategies to improve the quality of life and manage co-morbid anxiety and depression and encourage asthma patients' engagement in clinically tolerable jobs, may result in significant cost savings to the health system.

Adjusting Behavioural Surveillance and Assessing Disparities in the Impact of COVID-19 on Gay and Bisexual Men's HIV-Related Behaviour in Australia

COVID-19 has disrupted sexual behaviour and access to health systems. We adapted regular HIV behavioural surveillance of gay and bisexual men (GBM) in Australia in response to COVID-19, assessed the impact on the profile of the sample, the participants' HIV-related behaviour, and whether COVID-19 may have accentuated existing disparities in the Australian HIV epidemic. Data collected from five states during July 2017-June 2021 were included (N = 31,460). The emphasis on online recruitment after COVID-19 led to smaller sample sizes, greater geographic reach, and a higher proportion of bisexual-identifying participants. Most participants (88.1%) reported physical distancing and 52.1% had fewer sex partners due to COVID-19. In the COVID-19-affected rounds (July 2020-June 2021), the number of male partners, recent HIV testing and pre-exposure prophylaxis (PrEP) use all fell, and HIV risk among the smaller group of participants who reported casual sex increased. COVID-related changes were generally more pronounced among GBM aged under 25 years, participants from suburbs with fewer gay residents, and bisexual men. These groups should be prioritised when encouraging GBM to reengage with HIV testing services and effective prevention methods, like condoms and PrEP.

Antiretroviral Therapy Use, Viral Detectability and Fear of Onward Transmission Among People Living with HIV in Australia: Changes Between 1997 and 2018

This paper examines how antiretroviral therapy (ART) use and fears towards the onward transmission of HIV have changed among people living with HIV (PLHIV) in Australia between 1997 and 2018. Participants were recruited as part of the HIV Futures study, a large cross-sectional survey of PLHIV in Australia, in 1997, 2003, 2012 and 2018 (total n = 3889). ART use, viral load detectability, and fear of onward HIV transmission were compared between years. Predictors of onward transmission fear were assessed among the 2018 subsample. While ART use within our sample decreased between 1997 and 2003, it subsequently increased to 97% in 2018. Self-reported viral load undetectability steadily increased over time, up to 88% in 2018. Notably, fewer PLHIV reported being fearful of transmitting HIV in 2018 compared to all other years. Being unfamiliar with the undetectable = untransmissible health movement, and having a detectable or uncertain viral load at last test, were significant predictors of being fearful of onward HIV transmission. Beyond the immediate medical considerations of HIV treatment, these results suggest that the undetectable = untransmissible movement may play a critical role in attenuating burdens experienced by PLHIV in Australia and that such messaging, in tandem with early and consistent ART use, should remain a salient feature of heath messaging among this population.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ACTRN12622000655741.

Engagement with healthcare providers and healthcare system navigation among Australians with chronic conditions: a descriptive survey study

OBJECTIVES

With the rate of chronic conditions increasing globally, it is important to understand whether people with chronic conditions have the capacity to find the right care and to effectively engage with healthcare providers to optimise health outcomes.We aimed to examine associations between care navigation, engagement with health providers and having a chronic health condition among Australian adults.

DESIGN AND SETTING

This is a cross-sectional, 39-item online survey including the navigation and engagement subscales of the Health Literacy Questionnaire, completed in December 2018, in Australia. Binary variables (low/high health literacy) were created for each item and navigation and engagement subscale scores. Logistic regression analyses (estimating ORs) determined the associations between having a chronic condition and the navigation and engagement scores, while controlling for age, gender, level of education and income.

PARTICIPANTS

1024 Australians aged 18-88 years (mean=46.6 years; 51% female) recruited from the general population.

RESULTS

Over half (n=605, 59.0%) of the respondents had a chronic condition, mostly back pain, mental disorders, arthritis and asthma. A greater proportion of respondents with chronic conditions had difficulty ensuring that healthcare providers understood their problems (32.2% vs 23.8%, p=0.003), having good discussions with their doctors (29.1% vs 23.5%, p=0.05), discussing things with healthcare providers until they understand all they needed (30.5% vs 24.5%, p=0.04), accessing needed healthcare providers (35.7% vs 29.7%, p=0.05), finding the right place to get healthcare services (36.3% vs 29.2%, p=0.02) and services they were entitled to (48.3% vs 40.6%, p=0.02), and working out what is the best healthcare for themselves (34.2% vs 27.7%, p=0.03). Participants with chronic conditions were 1.5 times more likely to have low scores on the engagement (adjusted OR=1.48, p=0.03, 95% CI 1.05 to 2.08) and navigation (adjusted OR=1.43, p=0.026, 95% CI 1.043 to 1.970) subscales after adjusting for age, gender, income and education.

CONCLUSION

Upskilling in engagement and communication for healthcare providers and people with chronic conditions is needed. Codesigned, clearly articulated and accessible information about service entitlements and pathways through care should be made available to people with chronic conditions. Greater integration across health services, accessible shared health records and access to care coordinators may improve navigation and engagement.

Diagnostic delay of myositis: an integrated systematic review

BACKGROUND

Idiopathic inflammatory myopathies (IIM) are a heterogenous group of rare muscular autoimmune diseases characterised by skeletal muscle inflammation with possible diagnostic delay. Our aim was to review the existing evidence to identify overall diagnostic delay for IIM, factors associated with diagnostic delay, and people's experiences of diagnostic delay.

METHODS

Three databases and grey literature sources were searched. Diagnostic delay was defined as the period between the onset of symptoms and the year of first diagnosis of IIM. We pooled the mean delay using random effects inverse variance meta-analysis and performed subgroup analyses.

RESULTS

328 titles were identified from which 27 studies were included. Overall mean diagnostic delay was 27.91 months (95% CI 15.03-40.79, I2 = 99%). Subgroup analyses revealed a difference in diagnostic delay between non-inclusion body myositis (IBM) and IBM types. There was no difference in diagnostic delay between studies in which myositis specific autoantibodies (MSA) were tested or not tested. In countries with gatekeeper health systems, where primary care clinicians authorize access to specialty care, people experienced longer periods of diagnostic delay than people with IIM in countries with non-gatekeeper systems. While studies discussed factors that may influence diagnostic delay, significant associations were not identified. No qualitative studies examining people's experiences of diagnostic delay were identified.

CONCLUSION

Diagnostic delay of IIM has extensive impacts on the quality of life of people living with this disease. Understanding the experiences of people with IIM, from symptom onset to diagnosis, and factors that influence diagnostic delay is critical to inform clinical practice and training activities aimed at increasing awareness of this rare disease and expediting diagnosis.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42022307236 URL of the PROSPERO registration: https://www.crd.york.ac.uk/PROSPEROFILES/307236_PROTOCOL_20220127.pdf.

Frailty trajectory over one year among residential aged care (nursing home) residents

Objectives

Large population-based studies examining frailty trajectory found a linear increase in frailty over time. The pattern in which frailty changes over time for an individual person is less well-described. We examined the frailty trajectory of older adults living in aged-care in Australia.

Materials and methods

This secondary study used data from a randomised controlled trial involving 39 aged-care facilities in Australia. The trial intervention was an on-going pharmacist-led intervention occurring every 8 weeks over 12 months aimed at preventing medicine-induced deterioration and adverse reactions. Frailty was assessed using the Frailty Index. Participants were categorised as non-frail, pre-frail and frail. Individual frailty trajectory over 12 months was visualised using the alluvial plot. Case notes were examined to explore reasons for any rapid transitions in frailty status.

Results

A total of 248 participants was included. At baseline, 40.3% were non-frail and 59.7% were pre-frail. The proportion of participants who were non-frail and pre-frail decreased over time; 15.7% were frail at 6 months and 23.4% were frail at 12 months. Overall, twenty different combinations of frailty transitions were identified over 12 months. Retrospective analysis of case notes suggest that death or transition from non-frail to frail was often preceded by hospitalisation, falls, medication change or clinically significant deterioration in grip strength or cognition.

Conclusion

The degree of frailty increased over time, but there were variations in the individual trajectories. Regular monitoring of events that precede changes in frailty status is needed to identify strategies to prevent further deterioration in residents’ conditions.

Machine learning predicts the short-term requirement for invasive ventilation among Australian critically ill COVID-19 patients

OBJECTIVE(S)

To use machine learning (ML) to predict short-term requirements for invasive ventilation in patients with COVID-19 admitted to Australian intensive care units (ICUs).

DESIGN

A machine learning study within a national ICU COVID-19 registry in Australia.

PARTICIPANTS

Adult patients who were spontaneously breathing and admitted to participating ICUs with laboratory-confirmed COVID-19 from 20 February 2020 to 7 March 2021. Patients intubated on day one of their ICU admission were excluded.

MAIN OUTCOME MEASURES

Six machine learning models predicted the requirement for invasive ventilation by day three of ICU admission from variables recorded on the first calendar day of ICU admission; (1) random forest classifier (RF), (2) decision tree classifier (DT), (3) logistic regression (LR), (4) K neighbours classifier (KNN), (5) support vector machine (SVM), and (6) gradient boosted machine (GBM). Cross-validation was used to assess the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of machine learning models.

RESULTS

300 ICU admissions collected from 53 ICUs across Australia were included. The median [IQR] age of patients was 59 [50-69] years, 109 (36%) were female and 60 (20%) required invasive ventilation on day two or three. Random forest and Gradient boosted machine were the best performing algorithms, achieving mean (SD) AUCs of 0.69 (0.06) and 0.68 (0.07), and mean sensitivities of 77 (19%) and 81 (17%), respectively.

CONCLUSION

Machine learning can be used to predict subsequent ventilation in patients with COVID-19 who were spontaneously breathing and admitted to Australian ICUs.

The hunt for hidden hearing loss in humans: From preclinical studies to effective interventions

Many individuals experience hearing problems that are hidden under a normal audiogram. This not only impacts on individual sufferers, but also on clinicians who can offer little in the way of support. Animal studies using invasive methodologies have developed solid evidence for a range of pathologies underlying this hidden hearing loss (HHL), including cochlear synaptopathy, auditory nerve demyelination, elevated central gain, and neural mal-adaptation. Despite progress in pre-clinical models, evidence supporting the existence of HHL in humans remains inconclusive, and clinicians lack any non-invasive biomarkers sensitive to HHL, as well as a standardized protocol to manage hearing problems in the absence of elevated hearing thresholds. Here, we review animal models of HHL as well as the ongoing research for tools with which to diagnose and manage hearing difficulties associated with HHL. We also discuss new research opportunities facilitated by recent methodological tools that may overcome a series of barriers that have hampered meaningful progress in diagnosing and treating of HHL.

Evaluation of the Young, Deadly, Syphilis Free multi-media campaign in remote Australia

Introduction

Since 2011, remote Australian Aboriginal and Torres Strait Islander communities have experienced an outbreak of infectious syphilis, with young people aged 15–29 years over-represented in notifications. The Young Deadly Syphilis Free multi-media campaign was implemented in 12 remote regions in four Australian jurisdictions over nine months from 2017–2018. Campaign components included television and radio advertisements, social media posts, and health promotion resources available via a dedicated website. The aim of this research was to evaluate the impacts (proximal, mediator, distal) of the Young Deadly Syphilis Free campaign for young Aboriginal people and health and community workers residing in remote campaign regions.

Methods

A cross-sectional (post-only) evaluation design was used. Data were collected through online surveys; metrics for social media (Facebook, Instagram) were also collected to determine campaign engagement via social media. A 22-item young people survey assessed campaign awareness, exposure, message recognition and diagnostics (proximal variables); along with intended behaviour and knowledge and attitudes (mediator variables). A 24-item health and community worker survey assessed campaign awareness, exposure, message recognition and diagnostics (proximal variables); and changes in professional practice (distal variable). Descriptive statistics summarised demographic characteristics and univariate analysis examined associations between key variables.

Results

Just over half (n = 25, 58%) of young people and three quarters (n = 36; 75%) of health and community workers were aware of the campaign. Recognition of key campaign messages was high for both participant groups (>64%), and television, Facebook, and website were the most common campaign exposure routes. Positive impacts on intended behaviour (young people) and professional practice (health and community workers) were also reported. Facebook was effective in engaging some young people in campaign content and was preferred by young people for accessing information.

Conclusion

The findings point to the value of utilising a multi-media campaign in raising awareness about syphilis among young Aboriginal people and health and community workers in remote Australian regions. A longer-term campaign that accommodates the diverse needs of Aboriginal young people from geographically remote communities would optimise campaign impacts and support behavioural change.

Examining the prevalence of disordered eating in a cohort of young Australians presenting for mental health care at a headspace centre: results from a cross-sectional clinical survey study

OBJECTIVES

The aim of this study was to determine the prevalence of disordered eating in young people attending a headspace centre, an enhanced primary care centre providing early intervention services for mental health disorders for young people aged 12-25 years, in metropolitan Sydney.

DESIGN

Cross-sectional assessment of disordered eating symptoms and behaviours.

SETTING

An enhanced primary care youth mental health service in inner urban Sydney, Australia.

PARTICIPANTS

A sequential cohort of 530 young people aged 14-26 years presenting to headspace Camperdown for support with mental health concerns.

OUTCOME MEASURES

Participants completed a series of questionnaires online which included items assessing the presence of eating disorder symptoms and behaviours.

RESULTS

Over one-third of young people aged 14-26 years presenting to headspace Camperdown in a 22-month period reported symptoms of disordered eating. Of these, 32% endorsed overeating behaviours, 25% endorsed dietary restriction and 8% reported purging behaviours. In total, 44% reported engaging in one of more of these behaviours on a regular basis. Almost half reported experiencing significant shape and weight concerns. Eating disorder behaviours were particularly prevalent among female and gender-diverse participants (48% of females and 46% of gender-diverse participants compared with 35% of males) and overall scores across all of the eating disorder and body image items assessed were significantly higher for female participants compared with males.

CONCLUSIONS

Disordered eating behaviours and symptoms are common among those presenting to youth mental health primary care services. Proactive screening for these behaviours presents opportunities for early detection and specific interventions.

TRIAL REGISTRATION NUMBER

ACTRN12618001676202; Results.

Australian children's foot, ankle and leg problems in primary care: a secondary analysis of the Bettering the Evaluation and Care of Health (BEACH) data

OBJECTIVES

To explore children's foot, ankle and leg consultation patterns and management practices in Australian primary care.

DESIGN

Cross-sectional, retrospective study.

SETTING

Australia Bettering the Evaluation and Care of Health program dataset.

PARTICIPANTS

Data were extracted for general practitioners (GPs) and patients <18 years from April 2000 to March 2016 inclusive.

MAIN OUTCOME MEASURES

Demographic characteristics: sex, GP age groups (ie, <45, 45-54, 55+ years), GP country of training, patient age grouping (0-4, 5-9, 10-14, 15-18 years), postcode, concession card status, indigenous status, up to three patient encounter reasons, up to four encounter problems/diagnoses and the clinical management actioned by the GP.

RESULTS

Children's foot, ankle or leg problems were managed at a rate of 2.05 (95% CI 1.99 to 2.11) per 100 encounters during 229 137 GP encounters with children. There was a significant increase in the rate of foot, ankle and leg problems managed per 100 children in the population, from 6.1 (95% CI 5.3 to 6.8) in 2005-2006 to 9.0 (95% CI 7.9 to 10.1) in 2015-2016. Management of children's foot, ankle and leg problems were independently associated with male patients (30% more than female), older children (15-18 years were 7.1 times more than <1 years), male GPs (13% more) and younger GPs (<45 years of age 13% more than 55+). The top four most frequently managed problems were injuries (755.9 per 100 000 encounters), infections (458.2), dermatological conditions (299.4) and unspecified pain (176.3). The most frequently managed problems differed according to age grouping.

CONCLUSIONS

Children commonly present to GPs for foot, ankle and leg problems. Presentation frequencies varied according to age. Unexpectedly, conditions presenting commonly in adults, but rarely in children, were also frequently recorded. This data highlights the importance of initiatives supporting contemporary primary care knowledge of diagnoses and management of paediatric lower limb problems to minimise childhood burden of disease.

SARS-CoV-2 epitope-specific CD4+ memory T cell responses across COVID-19 disease severity and antibody durability

CD4+ T cells are central to long-term immunity against viruses through the functions of T helper 1 (TH1) and T follicular helper (TFH) cell subsets. To better understand the role of these subsets in coronavirus disease 2019 (COVID-19) immunity, we conducted a longitudinal study of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific CD4+ T cell and antibody responses in convalescent individuals who seroconverted during the first wave of the pandemic in Boston, MA, USA, across a range of COVID-19 disease severities. Analyses of spike (S) and nucleocapsid (N) epitope-specific CD4+ T cells using peptide and major histocompatibility complex class II (pMHCII) tetramers demonstrated expanded populations of T cells recognizing the different SARS-CoV-2 epitopes in most individuals compared with prepandemic controls. Individuals who experienced a milder disease course not requiring hospitalization had a greater percentage of circulating TFH (cTFH) and TH1 cells among SARS-CoV-2-specific cells. Analysis of SARS-CoV-2-specific CD4+ T cells responses in a subset of individuals with sustained anti-S antibody responses after viral clearance also revealed an increased proportion of memory cTFH cells. Our findings indicate that efficient early disease control also predicts favorable long-term adaptive immunity.

Changing Levels of Social Engagement with Gay Men Is Associated with HIV Related Outcomes and Behaviors: Trends in Australian Behavioral Surveillance 1998-2020

Changes to how gay, bisexual, and other men who have sex with men (GBM) connect with each other and with their communities have implications for HIV prevention. Social engagement with gay men (defined as having friends who are gay men and spending time with them) has been associated with HIV related outcomes over time among Australian GBM. Using data collected in national, repeated, cross-sectional surveys of GBM between 1998 and 2020 (N = 161,117), analyses of trends in the prevalence of gay social engagement (GSE) in Australia were conducted using linear regression. To assess changing associations with GSE at different time points in the HIV epidemic, three cross-sectional analyses were conducted on factors associated with high and low GSE in 1999/2000, 2009/2010, and 2019/2020 using bivariate and multivariable logistic regression. GSE (scored from 0 to 7) declined among all participants from 4.76 in 1998 to 4.04 in 2020 (p < 0.001) with a steeper decline among GBM aged under 25 years from 4.63 in 1998 to 3.40 in 2020 (p < 0.001). In all timepoints, high GSE was associated with older age, being university educated, full time employment, identifying as gay, recent HIV testing, and PrEP uptake. While mostly associated with protective behaviors, high GSE was also associated with some practices that may put GBM at risk of HIV infection such as drug-enhanced sex and group sex in the most recent timepoint. Changing levels of GSE have implications for health promotion among GBM, particularly how to engage GBM less connected to gay social networks.

A multimodal intervention to optimise antimicrobial use in residential aged care facilities (ENGAGEMENT): protocol for a stepped-wedge cluster randomised trial

BACKGROUND

Inappropriate antibiotic use can cause harm and promote antimicrobial resistance, which has been declared a major health challenge by the World Health Organization. In Australian residential aged care facilities (RACFs), the most common indications for antibiotic prescribing are for infections of the urinary tract, respiratory tract and skin and soft tissue. Studies indicate that a high proportion of these prescriptions are non-compliant with best prescribing guidelines. To date, a variety of interventions have been reported to address inappropriate prescribing and overuse of antibiotics but with mixed outcomes. This study aims to identify the impact of a set of sustainable, multimodal interventions in residential aged care targeting three common infection types.

METHODS

This protocol details a 20-month stepped-wedge cluster-randomised trial conducted across 18 RACFs (as 18 clusters). A multimodal multi-disciplinary set of interventions, the 'AMS ENGAGEMENT bundle', will be tailored to meet the identified needs of participating RACFs. The key elements of the intervention bundle include education for nurses and general practitioners, telehealth support and formation of an antimicrobial stewardship team in each facility. Prior to the randomised sequential introduction of the intervention, each site will act as its own control in relation to usual care processes for antibiotic use and stewardship. The primary outcome for this study will be antibiotic consumption measured using defined daily doses (DDDs). Cluster-level rates will be calculated using total occupied bed numbers within each RACF during the observation period as the denominator. Results will be expressed as rates per 1000 occupied bed days. An economic analysis will be conducted to compare the costs associated with the intervention to that of usual care. A comprehensive process evaluation will be conducted using the REAIM Framework, to enable learnings from the trial to inform sustainable improvements in this field.

DISCUSSION

A structured AMS model of care, incorporating targeted interventions to optimise antimicrobial use in the RACF setting, is urgently needed and will be delivered by our trial. The trial will aim to empower clinicians, residents and families by providing a robust AMS programme to improve antibiotic-related health outcomes.

TRIAL REGISTRATION

US National Library of Medicine Clinical Trials.gov ( NCT04705259 ). Prospectively registered in 12th of January 2021.

Australia as a global sink for the genetic diversity of avian influenza A virus

Most of our understanding of the ecology and evolution of avian influenza A virus (AIV) in wild birds is derived from studies conducted in the northern hemisphere on waterfowl, with a substantial bias towards dabbling ducks. However, relevant environmental conditions and patterns of avian migration and reproduction are substantially different in the southern hemisphere. Through the sequencing and analysis of 333 unique AIV genomes collected from wild birds collected over 15 years we show that Australia is a global sink for AIV diversity and not integrally linked with the Eurasian gene pool. Rather, AIV are infrequently introduced to Australia, followed by decades of isolated circulation and eventual extinction. The number of co-circulating viral lineages varies per subtype. AIV haemagglutinin (HA) subtypes that are rarely identified at duck-centric study sites (H8-12) had more detected introductions and contemporary co-circulating lineages in Australia. Combined with a lack of duck migration beyond the Australian-Papuan region, these findings suggest introductions by long-distance migratory shorebirds. In addition, on the available data we found no evidence of directional or consistent patterns in virus movement across the Australian continent. This feature corresponds to patterns of bird movement, whereby waterfowl have nomadic and erratic rainfall-dependant distributions rather than consistent intra-continental migratory routes. Finally, we detected high levels of virus gene segment reassortment, with a high diversity of AIV genome constellations across years and locations. These data, in addition to those from other studies in Africa and South America, clearly show that patterns of AIV dynamics in the Southern Hemisphere are distinct from those in the temperate north.

COVID-19 in low-tolerance border quarantine systems: Impact of the Delta variant of SARS-CoV-2

In controlling transmission of coronavirus disease 2019 (COVID-19), the effectiveness of border quarantine strategies is a key concern for jurisdictions in which the local prevalence of disease and immunity is low. In settings like this such as China, Australia, and New Zealand, rare outbreak events can lead to escalating epidemics and trigger the imposition of large-scale lockdown policies. Here, we develop and apply an individual-based model of COVID-19 to simulate case importation from managed quarantine under various vaccination scenarios. We then use the output of the individual-based model as input to a branching process model to assess community transmission risk. For parameters corresponding to the Delta variant, our results demonstrate that vaccination effectively counteracts the pathogen's increased infectiousness. To prevent outbreaks, heightened vaccination in border quarantine systems must be combined with mass vaccination. The ultimate success of these programs will depend sensitively on the efficacy of vaccines against viral transmission.

Informing the development of Australia's National Eating Disorders Research and Translation Strategy: a rapid review methodology

BACKGROUND

Eating disorders (EDs) are highly complex mental illnesses associated with significant medical complications. There are currently knowledge gaps in research relating to the epidemiology, aetiology, treatment, burden, and outcomes of eating disorders. To clearly identify and begin addressing the major deficits in the scientific, medical, and clinical understanding of these mental illnesses, the Australian Government Department of Health in 2019 funded the InsideOut Institute (IOI) to develop the Australian Eating Disorder Research and Translation Strategy, the primary aim of which was to identify priorities and targets for building research capacity and outputs. A series of rapid reviews (RR) were conducted to map the current state of knowledge, identify evidence gaps, and inform development of the national research strategy. Published peer-reviewed literature on DSM-5 listed EDs, across eight knowledge domains was reviewed: (1) population, prevalence, disease burden, Quality of Life in Western developed countries; (2) risk factors; (3) co-occurring conditions and medical complications; (4) screening and diagnosis; (5) prevention and early intervention; (6) psychotherapies and relapse prevention; (7) models of care; (8) pharmacotherapies, alternative and adjunctive therapies; and (9) outcomes (including mortality). While RRs are systematic in nature, they are distinct from systematic reviews in their aim to gather evidence in a timely manner to support decision-making on urgent or high-priority health concerns at the national level.

RESULTS

Three medical science databases were searched as the primary source of literature for the RRs: Science Direct, PubMed and OVID (Medline). The search was completed on 31st May 2021 (spanning January 2009-May 2021). At writing, a total of 1,320 articles met eligibility criteria and were included in the final review.

CONCLUSIONS

For each RR, the evidence has been organised to review the knowledge area and identify gaps for further research and investment. The series of RRs (published separately within the current series) are designed to support the development of research and translation practice in the field of EDs. They highlight areas for investment and investigation, and provide researchers, service planners and providers, and research funders rapid access to quality current evidence, which has been synthesised and organised to assist decision-making.

Transitions in general practice training: quantifying epidemiological variation in trainees' experiences and clinical behaviours

BACKGROUND

General Practice training in Australia is delivered through the apprenticeship model. General Practice supervisors support trainees transitioning from hospital-based work towards competent independent community-based practice. The timing and manner in which support should be provided is still not well understood. This study aimed to establish the variation in clinical and educational experiences and behaviours, and location, of general practice trainees' consultations by stage of their vocational training. It was hypothesised that change is greater in earlier stages of training.

METHODS

A cross-sectional analysis of data (2010-2018) from the Registrar Clinical Encounters in Training (ReCEnT) study, an ongoing cohort study of Australian GP registrars' in-consultation clinical and educational experience and behaviours. Multinomial logistic regression assessed the association of demographic, educational, and clinical factors in different stages of training. The outcome factor was the training term.

RESULTS

Two thousand four hundred sixteen registrars contributed data for 321,414 patient consultations. For several important variables (seeing patients with chronic disease; new patients; seeking in-consultation information or assistance; ordering pathology and imaging; and working in a small or regional practice), odds ratios were considerably greater for comparisons of Term 1 and 3, relative to comparisons of Term 2 and 3.

CONCLUSION

Differences experienced in demographic, clinical and educational factors are significantly more pronounced earlier in registrars' training. This finding has educational and training implications with respect to resource allocation, trainee supervision and curriculum design. Sociocultural learning theory enables an understanding of the impact of transitions on, and how to support, general practice trainees and supervisors.

COVID-19 Vaccination Uptake and Hesitancy in a National Sample of Australian Gay and Bisexual Men

Minority groups may face additional barriers to vaccination. In April-June 2021, we assessed the level of COVID-19 vaccination and willingness to be vaccinated in a national, online survey of 1280 gay and bisexual men in Australia. Over a quarter of the sample (28.0%) had been partially or fully vaccinated, and 80.0% of the unvaccinated were willing to be vaccinated. Vaccination was independently associated with older age, being university educated, and HIV status (with HIV-positive participants being more likely and untested participants less likely to be vaccinated). Willingness to be vaccinated was independently associated with living in a capital city and being university educated. Those who had lost income or their job due to COVID-19 were less willing to be vaccinated. Our results suggest encouraging COVID-19 vaccination among those with lower levels of health literacy and supporting those who have experienced financial stress because of the pandemic.

What are the effects of ethnicity, sexuality, disability and obesity on the odds of experiencing discrimination among Australian males? A nationwide cross-sectional survey

OBJECTIVES

The global public health community has been slow to acknowledge the important role of discrimination in health inequality. Existing evidence on discrimination is largely based on studies of specific subpopulations and specific forms of discrimination, with limited evidence from general population samples. We assessed the individual and combined effects of ethnicity, sexuality, disability and obesity on the likelihood of discrimination among a general population sample of Australian males.

DESIGN AND SETTING

We used data from The Australian Longitudinal Study on Male Health (n=15 988, with response rate of 35%) to estimate the prevalence of self-perceived discrimination within the preceding 2 years and we used binary logistic regression models to assess the individual and combined effects of ethnicity, sexuality, disability and obesity on discrimination.

PARTICIPANTS

13 763 adult males were included in this analysis.

RESULTS

One in five (19.7%) males reported experiencing discrimination in the preceding 2 years. Aboriginal and/or Torres Strait Islander males were nearly three times (OR=2.97, p<0.001) more likely to experience discrimination. Those born in Southern/Eastern Europe, Asia or Africa were at least twice more likely to report discrimination. Homosexual or bisexual males (35.2%; OR=2.23, p=<0.001), men with morbid obesity (29.2%; OR=1.91, p<0.001) and men with a disability (33.8%; OR=2.07, p<0.001) also had higher odds of experiencing discrimination. Those belonging to one (30.4%; OR=2.60, p<0.001) or two or more (38.2%; OR=3.50, p<0.001) risk groups were increasingly more likely to experience discrimination.

CONCLUSIONS

Discrimination was correlated with ethnicity, sexuality, obesity and disability. Belonging to two or more of the risk groups was associated with substantial increases in the likelihood of experiencing discrimination. Approaches to preventing discrimination need to acknowledge and address the impact of this intersectionality.

The Australian living guidelines for the clinical care of people with COVID-19: What worked, what didn't and why, a mixed methods process evaluation

Introduction

The Australian National COVID-19 Clinical Evidence Taskforce is producing living, evidence-based, national guidelines for treatment of people with COVID-19 which are updated each week. To continually improve the process and outputs of the Taskforce, and inform future living guideline development, we undertook a concurrent process evaluation examining Taskforce activities and experience of team members and stakeholders during the first 5 months of the project.

Methods

The mixed-methods process evaluation consisted of activity and progress audits, an online survey of all Taskforce participants; and semi-structured interviews with key contributors. Data were collected through five, prospective 4-weekly timepoints (beginning first week of May 2020) and three, fortnightly retrospective timepoints (March 23, April 6 and 20). We collected and analysed quantitative and qualitative data.

Results

An updated version of the guidelines was successfully published every week during the process evaluation. The Taskforce formed in March 2020, with a nominal start date of March 23. The first version of the guideline was published two weeks later and included 10 recommendations. By August 24, in the final round of the process evaluation, the team of 11 staff, working with seven guideline panels and over 200 health decision-makers, had developed 66 recommendations addressing 58 topics. The Taskforce website had received over 200,000 page views. Satisfaction with the work of the Taskforce remained very high (>90% extremely or somewhat satisfied) throughout. Several key strengths, challenges and methods questions for the work of the Taskforce were identified.

Conclusions

In just over 5 months of activity, the National COVID-19 Clinical Evidence Taskforce published 20 weekly updates to the evidence-based national treatment guidelines for COVID-19. This process evaluation identified several factors that enabled this achievement (e.g. an extant skill base in evidence review and convening), along with challenges that needed to be overcome (e.g. managing workloads, structure and governance) and methods questions (pace of updating, and thresholds for inclusion of evidence) which may be useful considerations for other living guidelines projects. An impact evaluation is also being conducted separately to examine awareness, acceptance and use of the guidelines.

The design of an evaluation framework for diabetes self-management education and support programs delivered nationally

BACKGROUND

The aim of this work was to develop a National Evaluation Framework to facilitate the standardization of delivery, quality, reporting, and evaluation of diabetes education and support programs delivered throughout Australia through the National Diabetes Services Scheme (NDSS). The NDSS is funded by the Australian Government, and provides access to diabetes information, education, support, and subsidized product across diverse settings in each state and territory of Australia through seven independent service-providers. This article reports the approach undertaken to develop the Framework.

METHODS

A participatory approach was undertaken, focused on adopting nationally consistent outcomes and indicators, nominating objectives and measurement tools, specifying evaluation processes, and developing quality standards. Existing programs were classified based on related, overarching indicators enabling the adoption of a tiered system of evaluation.

RESULTS

Two outcomes (i.e., improved clinical, reduced cost) and four indicators (i.e., improved knowledge and understanding, self-management, self-determination, psychosocial adjustment) were adopted from the Eigenmann and Colagiuri national consensus position statement for diabetes education. This allowed for the identification of objectives (i.e., improved empowerment, reduced distress, autonomy supportive program delivery, consumer satisfaction) and related measurement instruments. Programs were categorized as comprehensive, topic-specific, or basic education, with comprehensive programs allocated to receive the highest-level of evaluation. Eight quality standards were developed, with existing programs tested against those standards. Based on the results of testing, two comprehensive (OzDAFNE for people with type 1 diabetes, DESMOND for people with type 2 diabetes), and eight topic-specific (CarbSmart, ShopSmart, MonitorSmart, FootSmart, MedSmart, Living with Insulin, Insulin Pump Workshop, Ready Set Go - Let's Move) structured diabetes self-management education and support programs were nominated for national delivery.

CONCLUSIONS

The National Evaluation Framework has facilitated consistency of program quality, delivery, and evaluation of programs delivered by multiple service providers across diverse contexts. The Framework could be applied by other service providers who facilitate multiple diabetes education and support programs and could be adapted for use in other chronic disease populations where education and support are indicated.

FOXN1 forms higher-order nuclear condensates displaced by mutations causing immunodeficiency

The transcription factor FOXN1 is a master regulator of thymic epithelial cell (TEC) development and function. Here, we demonstrate that FOXN1 expression is differentially regulated during organogenesis and participates in multimolecular nuclear condensates essential for the factor’s transcriptional activity. FOXN1’s C-terminal sequence regulates the diffusion velocity within these aggregates and modulates the binding to proximal gene regulatory regions. These dynamics are altered in a patient with a mutant FOXN1 that is modified in its C-terminal sequence. This mutant is transcriptionally inactive and acts as a dominant negative factor displacing wild-type FOXN1 from condensates and causing athymia and severe lymphopenia in heterozygotes. Expression of the mutated mouse ortholog selectively impairs mouse TEC differentiation, revealing a gene dose dependency for individual TEC subtypes. We have therefore identified the cause for a primary immunodeficiency disease and determined the mechanism by which this FOXN1 gain-of-function mutant mediates its dominant negative effect.

Bisexual Men Living with HIV: Wellbeing, Connectedness and the Impact of Stigma

Social research with people living with HIV (PLHIV) rarely distinguishes between gay men and bisexual men. However, bisexual men may have unique experiences of HIV-related stigma and distinct support needs. In this paper, findings are presented from a cross-sectional survey of Australian PLHIV, which included the Berger (HIV) stigma scale. A total of 872 PLHIV completed the survey, of which 48 (6.0%) were bisexual men. Bisexual men reported higher levels of internalised HIV-related stigma, greater negative self-image and poorer emotional wellbeing than gay men. Bisexual men also reported less social support, less connection with lesbian, gay, bisexual, transgender and queer (LGBTQ) communities, and less connection with other PLHIV. Analysis of data from an open-text question revealed feelings of social isolation and fear of rejection was associated with participant's HIV diagnosis. Study findings suggest that existing social supports for PLHIV may not adequately address the unique support needs of bisexual men.

BCG vaccination to reduce the impact of COVID-19 in healthcare workers: Protocol for a randomised controlled trial (BRACE trial)

INTRODUCTION

BCG vaccination modulates immune responses to unrelated pathogens. This off-target effect could reduce the impact of emerging pathogens. As a readily available, inexpensive intervention that has a well-established safety profile, BCG is a good candidate for protecting healthcare workers (HCWs) and other vulnerable groups against COVID-19.

METHODS AND ANALYSIS

This international multicentre phase III randomised controlled trial aims to determine if BCG vaccination reduces the incidence of symptomatic and severe COVID-19 at 6 months (co-primary outcomes) compared with no BCG vaccination. We plan to randomise 10 078 HCWs from Australia, The Netherlands, Spain, the UK and Brazil in a 1:1 ratio to BCG vaccination or no BCG (control group). The participants will be followed for 1 year with questionnaires and collection of blood samples. For any episode of illness, clinical details will be collected daily, and the participant will be tested for SARS-CoV-2 infection. The secondary objectives are to determine if BCG vaccination reduces the rate, incidence, and severity of any febrile or respiratory illness (including SARS-CoV-2), as well as work absenteeism. The safety of BCG vaccination in HCWs will also be evaluated. Immunological analyses will assess changes in the immune system following vaccination, and identify factors associated with susceptibility to or protection against SARS-CoV-2 and other infections.

ETHICS AND DISSEMINATION

Ethical and governance approval will be obtained from participating sites. Results will be published in peer-reviewed open-access journals. The final cleaned and locked database will be deposited in a data sharing repository archiving system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04327206.

Home-Based Sleep Sensor Measurements in an Older Australian Population: Before and during a Pandemic

Older adults are susceptible to poor night-time sleep, characterized by short sleep duration and high sleep disruptions (i.e., more frequent and longer awakenings). This study aimed to longitudinally and objectively assess the changes in sleep patterns of older Australians during the 2020 pandemic lockdown. A non-invasive mattress-based device, known as the EMFIT QS, was used to continuously monitor sleep in 31 older adults with an average age of 84 years old before (November 2019-February 2020) and during (March-May 2020) the COVID-19, a disease caused by a form of coronavirus, lockdown. Total sleep time, sleep onset latency, wake after sleep onset, sleep efficiency, time to bed, and time out of bed were measured across these two periods. Overall, there was no significant change in total sleep time; however, women had a significant increase in total sleep time (36 min), with a more than 30-min earlier bedtime. There was also no increase in wake after sleep onset and sleep onset latency. Sleep efficiency remained stable across the pandemic time course between 84-85%. While this sample size is small, these data provide reassurance that objective sleep measurement did not deteriorate through the pandemic in older community-dwelling Australians.

Cell-free DNA TAPS provides multimodal information for early cancer detection

Multimodal, genome-wide characterization of epigenetic and genetic information in circulating cell-free DNA (cfDNA) could enable more sensitive early cancer detection, but it is technologically challenging. Recently, we developed TET-assisted pyridine borane sequencing (TAPS), which is a mild, bisulfite-free method for base-resolution direct DNA methylation sequencing. Here, we optimized TAPS for cfDNA (cfTAPS) to provide high-quality and high-depth whole-genome cell-free methylomes. We applied cfTAPS to 85 cfDNA samples from patients with hepatocellular carcinoma (HCC) or pancreatic ductal adenocarcinoma (PDAC) and noncancer controls. From only 10 ng of cfDNA (1 to 3 ml of plasma), we generated the most comprehensive cfDNA methylome to date. We demonstrated that cfTAPS provides multimodal information about cfDNA characteristics, including DNA methylation, tissue of origin, and DNA fragmentation. Integrated analysis of these epigenetic and genetic features enables accurate identification of early HCC and PDAC.

Codesign and implementation of an equity-promoting national health literacy programme for people living with inflammatory bowel disease (IBD): a protocol for the application of the Optimising Health Literacy and Access (Ophelia) process

INTRODUCTION

Non-government organisations (NGOs) often represent people who are underserved or experiencing vulnerability. Crohn's & Colitis Australia (CCA) is aware that many Australians with inflammatory bowel disease (IBD) are not reached by current communication and engagement activities. The aim of the CCA IBD project is to implement the Optimising Health Literacy and Access (Ophelia) process over 3 years to collaboratively codesign ways to improve delivery of information, services and resources for people with IBD and their carers.

METHODS AND ANALYSIS

Health literacy and other data for phase 1 will be collected using the Health Literacy Questionnaire, eHealth Literacy Questionnaire, IBD-related questions and qualitative interviews with people with IBD and their carers to ascertain their lived experience. Quantitative data will be analysed using descriptive statistics and cluster analysis. Identified clusters will be combined with qualitative data to develop vignettes (narratives of people's experiences of living with IBD) for stakeholder workshops to generate ideas for useful, accessible and sustainable solutions for identified health literacy needs. Selection and testing of health literacy actions happens in phase 2 and implementation and evaluation in phase 3 (2021-2023). Outcomes of this project include giving voice to people living with IBD, their carers and frontline healthcare practitioners. Genuine codesign informs the development and implementation of what is needed and wanted to improve access to and availability and quality of information and resources that support people to manage their health. There is potential for other NGOs to use the CCA Ophelia model in other health contexts to improve engagement with and understanding of the needs of the people they serve and to reduce health inequalities and improve health outcomes.

ETHICS AND DISSEMINATION

Ethics approval for Ophelia phase 1 has been obtained from the Human Research Ethics Committee of Swinburne University of Technology (Ref: 20202968-4652) and by the South West Sydney Local Health District Research and Ethics Office for the purposes of questionnaire recruitment at Liverpool Hospital (Ref: 20202968-4652). Dissemination of the study findings will be the national codesign process and ownership development across the CCA community and through the genuine engagement of clinicians and relevant managers across Australia. The model and process will be directly distributed to international IBD associations and to other NGOs. It will also be disseminated through publication in a peer-reviewed journal, conference presentations and public reports on the CCA and Swinburne University of Technology website.

General practitioners' (GPs) understanding and views on breast density in Australia: a qualitative interview study

OBJECTIVES

To understand general practitioners' (GPs') awareness and knowledge of mammographic breast density (BD) and their perspectives around information and potential notification of BD for women.

DESIGN

Qualitative study using semistructured telephone interviews. Interviews were audiorecorded, transcribed and analysed using framework analysis.

SETTING

Australia.

PARTICIPANTS

Australian GPs (n=30).

RESULTS

GPs had limited knowledge of BD and little experience discussing BD with women. There were mixed views on notification of BD with some GPs believing this information would help informed decision making about breast health and that women have the right to know any information about their bodies. While others were concerned about causing unnecessary anxiety and were worried about the uncertainty about what to advise women to do with this information, particularly in relation to supplemental breast screening. The need for an equitable system where all women are either notified or not, and also provided with publicly funded supplemental screening was raised by GPs. Overall, there was high interest in education, training and support around the topic of BD.

CONCLUSIONS

Australian GPs require education, support and evidence-based guidelines to have discussions with women with dense breasts and help manage their risk, especially if widespread notification is to be introduced in population-based screening programmes.

Prevalence and patterns of multimorbidity in Australian baby boomers: the Busselton healthy ageing study

BACKGROUND AND OBJECTIVE

Chronic medical conditions accumulate within individuals with age. However, knowledge concerning the trends, patterns and determinants of multimorbidity remains limited. This study assessed the prevalence and patterns of multimorbidity using extensive individual phenotyping in a general population of Australian middle-aged adults.

METHODS

Participants (n = 5029, 55% female), born between 1946 and 1964 and attending the cross-sectional phase of the Busselton Healthy Ageing Study (BHAS) between 2010 and 2015, were studied. Prevalence of 21 chronic conditions was estimated using clinical measurement, validated instrument scores and/or self-reported doctor-diagnosis. Non-random patterns of multimorbidity were explored using observed/expected (O/E) prevalence ratios and latent class analysis (LCA). Variables associated with numbers of conditions and class of multimorbidity were investigated.

RESULTS

The individual prevalence of 21 chronic conditions ranged from 2 to 54% and multimorbidity was common with 73% of the cohort having 2 or more chronic conditions. (mean ± SD 2.75 ± 1.84, median = 2.00, range 0-13). The prevalence of multimorbidity increased with age, obesity, physical inactivity, tobacco smoking and family history of asthma, diabetes, myocardial infarct or cancer. There were 13 pairs and 27 triplets of conditions identified with a prevalence > 1.5% and O/E > 1.5. Of the triplets, arthritis (> 50%), bowel disease (> 33%) and depression-anxiety (> 33%) were observed most commonly. LCA modelling identified 4 statistically and clinically distinct classes of multimorbidity labelled as: 1) "Healthy" (70%) with average of 1.95 conditions; 2) "Respiratory and Atopy" (11%, 3.65 conditions); 3) "Non-cardiometabolic" (14%, 4.77 conditions), and 4) "Cardiometabolic" (5%, 6.32 conditions). Predictors of multimorbidity class membership differed between classes and differed from predictors of number of co-occurring conditions.

CONCLUSION

Multimorbidity is common among middle-aged adults from a general population. Some conditions associated with ageing such as arthritis, bowel disease and depression-anxiety co-occur in clinically distinct patterns and at higher prevalence than expected by chance. These findings may inform further studies into shared biological and environmental causes of co-occurring conditions of ageing. Recognition of distinct patterns of multimorbidity may aid in a holistic approach to care management in individuals presenting with multiple chronic conditions, while also guiding health resource allocation in ageing populations.