Boosting inpatient exercise after hip fracture using an alternative workforce: a mixed methods implementation evaluation.

BACKGROUND: Hip fracture has a devastating impact on individuals and is an increasing burden for health systems and society. Compared to usual care, increased physiotherapy provision has demonstrated efficacy in improving patient and health service outcomes in this population. However, physiotherapy workforce challenges prevent sustained implementation. METHODS: Our aim was to evaluate the safety, feasibility, acceptability, effectiveness and implementation cost of thrice daily physiotherapy for patients in the acute care setting after hip fracture at two public hospitals. We added twice-daily exercise implemented by an alternative workforce, to usual care consisting of daily mobility practice by a physiotherapist. Sites identified their preferred alternative workforce, with pre-registration physiotherapy students and allied health assistants chosen. We used a mixed methods approach, using the Consolidated Framework for Implementation Research (CFIR) as a determinant framework to guide implementation planning and data collection. We compared hospital length of stay data to a reference cohort. RESULTS: We recruited 25 patients during the study period. Acute care hospital length of stay decreased from 11 days in the reference cohort to 8 days in the BOOST cohort (mean difference - 3.3 days, 95%CI -5.4 to -1.2 days, p = 0.003). Intervention fidelity was 72% indicating feasibility, no safety concerns were attributed to the intervention, and uptake was 96% of all eligible patients. The intervention was acceptable to patients, carers and healthcare providers. This intervention was cost-effective from the acute orthopaedic service perspective. CONCLUSION: Higher daily frequency of physiotherapy can be safely, feasibly and effectively implemented by an alternative workforce for patients in the acute care setting following hip fracture surgery.

Validity and Accuracy of Step Count as an Indicator of a Sedentary Lifestyle in People With Chronic Obstructive Pulmonary Disease.

OBJECTIVE: To determine the validity and accuracy of <5000 steps/day as a sedentary lifestyle indicator, and the optimal step count cut point value for indicating a sedentary lifestyle in people with chronic obstructive pulmonary disease (COPD). DESIGN: Analysis of baseline data from a randomized clinical trial. SETTING: Sydney, Australia. PARTICIPANTS: Stable COPD on the waitlist for pulmonary rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Step count and time in sedentary behavior (SB) were assessed using thigh-worn accelerometry. A sedentary lifestyle was defined as <5000 steps/day. Pearson correlation coefficients were analyzed between step count and time spent in SB. Sensitivity, specificity, and accuracy were calculated for the <5000 steps/day threshold. Receiver operating characteristic curves with the area under the curve were computed for step count in identifying a sedentary lifestyle. RESULTS: 69 people with COPD (mean age=74 years, SD=9; forced expiratory volume in 1 second, mean=55%, SD=19 predicted) had sufficient wear data for analysis. There was a moderate inverse correlation between step count and time spent in SB (r=-0.58, P<.001). Step count had a fair discriminative ability for identifying a sedentary lifestyle (area under the curve=0.80, 95% confidence interval [CI], 0.68-0.91). The <5000 steps/day threshold had a sensitivity, specificity, and accuracy of 82% (95% CI, 70-94), 70% (95% CI, 54-86), and 78%, respectively. A lower threshold of <4300 steps/day was more accurate for ruling in a sedentary lifestyle. CONCLUSIONS: Compared with thigh-worn accelerometry, <5000 steps/day is a valid and reasonably accurate indicator of a sedentary lifestyle in this population.

A mixed methods study of Aboriginal health workers' and exercise physiologists' experiences of co-designing chronic lung disease 'yarning' education resources.

BACKGROUND: Despite the high incidence of chronic obstructive pulmonary disease (COPD) in Aboriginal communities in Australia, Aboriginal Health Workers (AHWs) have limited knowledge about effective management. AIM: To evaluate an online education program, co-designed with AHWs and exercise physiologists (EPs) or physiotherapists (PTs), to increase knowledge about COPD and its management. METHODS: AHWs and EPs from four Aboriginal Community Controlled Health Services (ACCHS) were recruited. An Aboriginal researcher and a physiotherapist experienced in COPD management and pulmonary rehabilitation (PR) delivered seven online education sessions. These sessions used co-design principles and an Aboriginal pedagogy framework '8 Ways of learning', which incorporates Aboriginal protocols and perspectives to realign teaching techniques and strengthen learning outcomes. Topics covered were: How the lungs work; What is COPD; Medications and how to use inhalers and COPD Action Plans; Why exercise is important; Managing breathlessness; Healthy eating; Managing anxiety and depression. After each session, AHWs with support from EPs, co-designed education 'yarning' resources using Aboriginal ways of learning to ensure topics were culturally safe for the local Aboriginal community and practiced delivering this at the following session. At the end of the program participants completed an anonymous online survey (5-point Likert scale) to assess satisfaction, and a semi-structured interview about their experience of the online education. RESULTS: Of the 12 participants, 11 completed the survey (7 AHWs, 4 EPs). Most (90%) participants strongly agreed or agreed that the online sessions increased knowledge and skills they needed to support Aboriginal patients with COPD. All (100%) participants felt: their cultural perspectives and opinions were valued and that they were encouraged to include cultural knowledge. Most (91%) reported that delivering their own co-designed yarning scripts during the online sessions improved their understanding of the topics. Eleven participants completed semi-structured interviews about participating in online education to co-design Aboriginal 'yarning' resources. Themes identified were: revealing the Aboriginal lung health landscape; participating in online learning; structuring the online education sessions; co-designing with the facilitators. CONCLUSIONS: Online education using co-design and 8 Ways of learning was rated highly by AHWs and EPs for improving COPD knowledge and valuing cultural perspectives. The use of co-design principles supported the cultural adaptation of COPD resources for Aboriginal people with COPD. TRIAL REGISTRATION: PROSPERO (registration number: CRD42019111405).

Implementing evidence into practice to improve chronic lung disease management in Indigenous Australians: the breathe easy, walk easy, lungs for life (BE WELL) project (protocol).

BACKGROUND: Strong evidence exists for the benefits of pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD), however the availability of culturally safe PR for Aboriginal and Torres Strait Islander (Indigenous) Peoples is limited. The study aims to determine whether PR can be implemented within Aboriginal Community Controlled Health Services (ACCHS) to improve outcomes for Indigenous people with COPD. METHODS: Multi-centre cohort study using participatory action research guided by the Knowledge-to-Action Framework. ACCHS supportive of enhancing services for chronic lung disease will be recruited. Aboriginal Health Workers (AHW) and the exercise physiologist (EP) or physiotherapist (PT) within these ACCHS will attend a workshop aimed at increasing knowledge and skills related to management of COPD and the provision of PR. Indigenous people with COPD will be invited to attend an 8-week, twice weekly, supervised PR program. OUTCOMES: AHW, EP/PT knowledge, skills and confidence in the assessment and management of COPD will be measured before and immediately after the BE WELL workshop and at 3, 6 and 12 months using a survey. PR participant measures will be exercise capacity (6-minute walk test (6MWT), health-related quality of life and health status at commencement and completion of an 8-week PR program. Secondary outcomes will include: number, length and cost of hospitalisations for a COPD exacerbation in 12-months prior and 12-months post PR; local contextual factors influencing implementation of PR; specific respiratory services provided by ACCHS to manage COPD prior to project commencement and at project completion. Repeated measures ANOVA will be used to evaluate changes in knowledge and confidence over time of AHWs and EP/PTs. Paired t-tests will be used to evaluate change in patient outcomes from pre- to post-PR. Number of hospital admissions in the 12 months before and after the PR will be compared using unpaired t-tests. DISCUSSION: Pulmonary rehabilitation is an essential component of best-practice management of COPD and is recommended in COPD guidelines. Indigenous peoples have limited access to culturally safe PR programs. This study will evaluate whether PR can be implemented within ACCHS and improve outcomes for Indigenous people with COPD. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001337369, Registered 2nd September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373585&isClinicalTrial=False.

Patterns and Correlates of Sedentary Behaviour Accumulation and Physical Activity in People with Chronic Obstructive Pulmonary Disease: A Cross-Sectional Study.

Few studies have used 24-hour accelerometery to characterise posture and movement patterns in people with chronic obstructive pulmonary disease (COPD). This study aimed to quantify sedentary behaviour (SB), patterns of SB accumulation and physical activity (PA) in people with COPD, and to examine physiological and functional capacity correlates of total SB and patterns of SB accumulation. SB and PA were assessed continuously over seven days using thigh-worn accelerometery in people with COPD. Participants were regarded as "sedentary" if combined sitting/reclining time accounted for ≥70% of waking wear time. Differences in patterns of SB accumulation and PA were compared between "sedentary" and "non-sedentary" participants. Physiological and functional capacity correlates of SB were explored using univariate analysis. Sixty-nine people with COPD (mean (SD) age 74 (9) years, FEV1 55% (19) predicted) had sufficient wear data for analysis. Mean sedentary time was 643 (105) minutes/day (71% (11) of waking wear time), of which 374 (142) minutes/day were accumulated in prolonged bouts of ≥30 min. "Sedentary" participants had a more unfavourable pattern of SB accumulation and spent less time in PA of any intensity. Sedentary time, expressed as a proportion of waking wear time, was inversely correlated with light (r = -0.97, p < .01) and moderate-to-vigorous intensity PA (r = -0.55, p < .01) and exercise capacity (r = -0.33, p < .01), but not with age, body mass index or lung function. People with COPD had high total SB and accumulated the majority of SB in prolonged bouts. High total SB was correlated with low physical activity and exercise tolerance.

Aerobic exercise training may improve nerve function in type 2 diabetes and pre-diabetes: A systematic review.

Diabetic neuropathy is a major complication of type 2 diabetes. Emerging evidence also suggests that people with pre-diabetes may develop similar symptoms related to nerve dysfunction. While regular exercise provides many benefits to patients with diabetes, whether exercise influences nerve function has not been established. As such, the aim of this systematic review was to evaluate current evidence regarding the effect of exercise training on the progression and development of diabetic neuropathy. A systematic search of MEDLINE (Ovid), CINAHL, AMED, PEDro, the Cochrane Library, Embase, and Scopus databases identified a total of 12 studies that were eligible for inclusion in this systematic review. Quality rating and data extraction were performed by two independent reviewers. The 12 included studies examined people with pre-diabetes (n = 1) and with type 2 diabetes (n = 11). There was heterogeneity of study quality and exercise type and dosage among these studies. Eleven studies reported that exercise training had a positive influence on nerve function or neuropathy-related symptoms; and only one study reported mild adverse events. Evidence from this systematic review suggests aerobic exercise training may positively influence nerve function among people with type 2 diabetes, with minimal risk of adverse events. Further research will be required to determine the optimal dosage of exercise training and the effect on nerve function in pre-diabetes and in women with previous gestational diabetes. This review is registered on PROSPERO (CRD42018088182).

Early intervention for chronic obstructive pulmonary disease by practice nurse and GP teams: a cluster randomized trial.

BACKGROUND: Early detection and intervention for chronic obstructive pulmonary disease (COPD) could potentially slow disease progress and minimize harm. OBJECTIVES: To assess the effectiveness of early intervention by a practice nurse-GP team on quality of life (QoL) and process of care in patients with newly diagnosed COPD, compared with usual care. Nurses and GPs in intervention practices were educated to develop and implement disease management plans for COPD. METHODS: A 12-month, multicentre, pragmatic randomized controlled trial with blinded outcome assessment was conducted. Participants were current and former smokers aged 40 to 85 years newly identified as having COPD on post-bronchodilator spirometry. The primary outcome was health-related QoL, assessed with the St George's Respiratory Questionnaire (SGRQ). Secondary outcome measures were other QoL measures, lung function, disease knowledge, smoking and immunization status, inhaler technique and health service use. RESULTS: Of the 10 234 patients from 36 practices in Sydney invited to a case-finding appointment, 1641 (16%) attended and 287 (18%) were diagnosed with COPD. Nineteen practices (144 patients) were randomized to the intervention group and 17 practices (110 patients) to the control group. Only 15.3% (n = 22) patients in the intervention group saw the nurse for COPD care following case finding. There was no between-group difference in SGRQ score at follow-up (mean difference -0.21; P = 0.86). Influenza vaccination was higher in the intervention group (OR 2.31: P = 0.035), but there were no other significant between-group differences in outcomes. CONCLUSION: Intervention uptake was low and had no additional beneficial effect, over usual care, on participants' health-related QoL.

Resourcing an evolution of roles in general-practice: a study to determine the validity and reliability of tools to assist nurses and patients to assess physical activity.

Traditionally, GPs have been responsible for physical activity (PA) assessment within the general practice setting. Multiple questionnaires are available to support uptake of PA assessment but less than 30% of patients are assessed. A range of barriers hamper uptake. Evidence indicates that practice nurses (PNs) and patients are resourceful members of the general practice team but have been underutilised. This study assessed the validity and reliability of two instruments for assessing PA, administered by PNs and patients. The study aimed to identify robust tool(s) to support the evolving role of PNs and patients in prevention and management strategies in general practice. A purposive sample of PNs and patients from general practices in Sydney was invited to participate. The results of the PN- or patient-administered general practice physical activity questionnaire (GPPAQ) and the three-question physical activity questionnaire (3Q) were compared against accelerometer activity. The study examined agreement in classification of PA levels according to Australian PA recommendations. Validity showed low-moderate correlations between accelerometer and GPPAQ (rho=0.26), 3Q (rho=0.45). Seven-day test-retest reliability intraclass correlation coefficients (ICCs) were 0.82-0.95 for GGPAQ and 0.94-0.98 for 3Q. Agreement with PA recommendations was moderate for GPPAQ (kappa 0.73, 95% CI, 0.56-0.85) and fair for 3Q (kappa 0.62, 95% CI, 0.47-0.78). Although 3Q demonstrated higher correlation with accelerometry, GPPAQ demonstrated higher agreement with PA guidelines. Given GPPAQ showed reasonable rigour, it may prove useful for PN and patient use.

Improving musculoskeletal physiotherapists' confidence in patient-centred care informed by acceptance and commitment therapy: A descriptive study.

BACKGROUND: Patient-centred care is essential for high quality musculoskeletal care, however, few evidence-based opportunities exist that address the barriers to implementation for clinicians. OBJECTIVE: To develop and evaluate a simulation-based educational strategy for musculoskeletal physiotherapists to increase knowledge and confidence in patient-centred care. METHODS: Repeated-measures, single-group educational interventional descriptive study. Primary outcome was participant-reported knowledge and confidence in patient-centred care. Customized survey data was collected at baseline (T1) (N = 22), immediately after a face-to-face workshop (T2) (N = 22), and six weeks after the workshop (T3) (N = 17). Secondary outcomes included sustained implementation using the Normalization Measure Development (NoMAD) tool. Repeated-measures ANOVA was used to analyse primary outcomes. RESULTS: Our participants were typically female (72%), early career (mean 3.3 years post-graduate) and culturally diverse (67%). Significant increases in participant confidence were noted at all time points on all five learning outcomes (repeated measures ANOVA, p < 0.001 to p = 0.009). Participants had very high baseline knowledge and no further increases were found following the intervention (p > 0.05). Normalization Measure Development data indicated high coherence, high cognitive participation, and high reflexive monitoring, with neutral results for collective action. CONCLUSION: A novel, psychologically-informed, simulation-based educational strategy is effective in improving musculoskeletal physiotherapist confidence in patient-centred care. Participants reported implementation of skills learnt in the workshop into subsequent clinical practice.

Do people with existing chronic conditions benefit from telephone coaching? A rapid review.

OBJECTIVE: To examine the effectiveness of telephone-based coaching services for the management of patients with chronic diseases. METHODS: A rapid scoping review of the published peer reviewed literature, using Medline, Embase, CINAHL, PsychNet and Scopus. We included studies involving people aged 18 years or over with one or more of the following chronic conditions: type 2 diabetes, congestive cardiac failure, coronary artery disease, chronic obstructive pulmonary disease and hypertension. Patients were identified as having multi-morbidity if they had an index chronic condition plus one or more other chronic condition. To be included in this review, the telephone coaching had to involve two-way conversations by telephone or video phone between a patient and a provider. Behaviour change, goal setting and empowerment are essential features of coaching. RESULTS: The review found 1756 papers, which was reduced to 30 after screening and relevance checks. Most coaching services were planned, as opposed to reactive, and targeted patients with complex needs who had one or more chronic disease. Several studies reported improvements in health behaviour, self-efficacy, health status and satisfaction with the service. More than one-third of the papers targeted vulnerable people and telephone coaching was found to be effective for these people. CONCLUSIONS: Telephone coaching for people with chronic conditions can improve health behaviour, self-efficacy and health status. This is especially true for vulnerable populations who had difficulty accessing health services. There is less evidence for improvements in quality of life and patient satisfaction with the service. The evidence for improvements in health service use was limited. This rapid scoping review found that telephone-based coaching can enhance the management of chronic disease, especially for vulnerable groups. Further work is needed to identify what models of telephone coaching are most effective according to patients' level of risk and co-morbidity. What is known about the topic? With the increasing prevalence of chronic diseases more demands are being made of limited health services and resources. Telephone health coaching for people with or at risk of chronic diseases is seen as a means of supporting people to manage their health and reducing the burden on the healthcare system. What does this paper add? Telephone coaching interventions were effective for vulnerable people with chronic disease(s). Often the vulnerable populations had worse control of their chronic condition at baseline and demonstrated the greatest improvement compared with those with better control at baseline. Planned (i.e. weekly or monthly telephone calls to support the patients with chronic disease) and unscripted telephone coaching interventions appear to be most effective for improving self-management skills in people from vulnerable groups: the planned telephone coaching services had the advantage of regular contact and helping people develop their skills over time, whereas the unscripted aspect allowed the coach to tailor support to the patient's individual needs What are the implications for practitioners? Telephone coaching is an effective means of supporting people with chronic diseases to manage their own health. Further work is needed to embed telephone coaching within existing services. Good linkages with the patient's general practitioner are important. This might be a regular report, updates via the patient e-health record, or provision for contact if a problem is identified or linking to the patient e-health record.

Activating patients with chronic disease for self-management: comparison of self-managing patients with those managing by frequent readmissions to hospital.

Understanding the factors that activate people to self-manage chronic disease is important in improving uptake levels. If the many frequent hospital users who present with acute exacerbations of chronic disease were to self-manage at home, some hospital admissions would be avoided. Patient interview and demographic, psychological, clinical and service utilisation data were compared for two groups of patients with chronic disease: those attending self-management services and those who managed by using hospital services. Data were analysed to see whether there were differences that might explain the two different approaches to managing their conditions. The two groups were similar in terms of comorbidity, age, sex, home services, home support and educational level. Self-managing patients were activated by their clinician, accepted their disease, changed their identity, confronted emotions and learnt the skills to self-manage and avoid hospital. Patients who frequently used hospital services to manage their chronic disease were often in denial about their chronic disease, hung on to their identity and expressed little emotional response. However, they reported a stronger sense of coherence and rated their health more highly than self-managing patients. This study shed light on the process of patient activation for self-management. A better understanding of the process of patient activation would encourage clinicians who come into contact with frequently readmitted chronic disease patients to be more proactive in supporting self-management.

Transition to a virtual model of physiotherapy and exercise physiology in response to COVID-19 for people in a rural Australia: Is it a viable solution to increase access to allied health for rural populations?

Virtual healthcare has the potential to increase access to allied health for people living in rural areas, but challenges in delivery of such models have been reported. The COVID-19 pandemic provided an opportunity for a rural practice of physiotherapists and exercise physiologists to transition service delivery to a virtual model of care which utilised a combination of phone, video, an exercise app and/or paper handouts. This study aimed to evaluate the uptake and outcomes from virtual delivery of allied health services, and to describe patient and clinician experiences of the virtual model of care. A parallel convergent mixed methods study was conducted. De-identified data from patients who were offered the virtual service between 15 March 2020 and 30 September 2020 were extracted from the database of the rural practice, as were data from patients attending the practice in-person during the same time in 2019 to serve as a historical comparison. De-identified data from a monthly survey tracking clinician experiences of delivering care virtually was also obtained from the practice. Quantitative data were presented descriptively. Between-group differences were compared using independent samples t-tests, and within-group longitudinal changes compared using paired t-tests. Semi-structured interviews were conducted among a purposive sample of patients using the virtual service, and focus groups conducted among clinicians providing this model of care. Qualitative data were recorded and transcribed verbatim, then thematic analysis conducted. During the study period, the practice delivered 4% (n = 242) consultations virtually. Thirty-seven of the 60 patients (62%) using the virtual service were new referrals. Patients attended fewer sessional appointments virtually and a smaller proportion of patients reported high satisfaction with virtual care, compared to those who received in-person care the previous year (p < .05). Clinician confidence in delivering virtual care did not change significantly over time (p>.05), though clinicians not providing virtual care in a given month perceived their lower confidence than those who did provide virtual care (p < .05). Five themes influencing the success of virtual allied health provision emerged from patient interviews and clinician focus groups: adaptation of program elements for virtual delivery, conduct of virtual treatment, clinician flexibility, patient complexity and communication. The theme of communication influenced all the other themes. Virtual healthcare is a potential solution to address lack of access to allied health practitioners in rural areas, but may not suit all patients. Establishing a therapeutic relationship and ensuring people have access to adequate resources prior to virtual care delivery will optimise successful adoption of virtual care models. A hybrid model incorporating limited in-person consultations with virtual consultations appears a more viable option.

Unplanned return visits to emergency in a regional hospital.

OBJECTIVE: The aim of this study was to determine the patient characteristics associated with unplanned return visits, using routinely collected hospital data, to assist in developing strategies to reduce their occurrence. METHODS: Emergency department data from a regional hospital were analysed using univariate and multivariate methods to determine the influence of clinical, service usage and demographic patient characteristics on unplanned return visits. RESULTS: Around 80% of the 16000 patients attending emergency presented on only one occasion in a year. Five per cent of patients presented with an unplanned return visit. Older patients, those with minor and low urgency conditions and with non-psychotic mental health conditions, those presenting during winter and after hours were significantly more likely to present as unplanned return visits. CONCLUSION: Although patient characteristics associated with unplanned return visits have been identified, the reasons underpinning the unplanned return visit rate, such as patient service preference and attitudes, need to be more fully investigated.

What distinguishes clinicians who better support patients for chronic disease self-management?

Many frequent readmissions due to acute exacerbations of chronic disease could be prevented if patients self-managed. This study explored factors involved in patient activation for chronic disease self-management by qualitative analysis of interview data from hospital and community-based clinicians and patients. All clinicians reported that many frequently readmitted patients did not readily take up referral to chronic disease self-management services. This reluctance was compounded by system or access barriers. Clinicians who had a defined role in chronic disease management and patient-centred and behaviour change skills reported that although some patients were more resistant than others, patients could be persuaded to adopt self-management behaviours. Hospital clinicians and GPs were more inclined to attribute blame to clinical, social and personal patient factors, such as difficulty with support at home, social circumstances and reluctance to take responsibility. Investment in extending the skills and role of hospital clinicians and GPs to take a more supportive role in patient uptake of referrals to chronic disease self-management services would reduce hospital readmissions. Improvements in access to chronic disease self-management and GP services are also needed to address failure to take up chronic disease self-management.

Frequent emergency attenders: is there a better way?

BACKGROUND: Understanding the reasons for frequent re-attendances will assist in developing solutions to hospital overcrowding. This study aimed to identify the factors associated with frequent re-attendances in a regional hospital thereby highlighting possible solutions to the problem. METHODS: A retrospective analysis was performed on emergency department data from 2008. Frequent re-attenders were defined as those with four or more presentations in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on re-presentations using multivariate analysis. RESULTS; A total of 8% of the total patients presenting to emergency re-attended four or more times in the year. Frequent re-attenders were older, presented with an unplanned returned visit and had a diagnosis of neurosis, chronic obstructive pulmonary disease (COPD), convulsions, dyspnoea or repeat prescriptions, follow-up examinations or dressings and sutures and less likely to present in summer. Frequent re-attendances were unrelated to sex, time of presentation or country of birth. CONCLUSIONS: Diversion of patients with minor conditions to alternative services; referral of COPD patients to follow-up respiratory services and patients with neurosis to community mental health services would reduce emergency utilisation. Improving access to and resourcing of alternative non-hospital services should be investigated to reduce emergency overcrowding.

Patient related factors in frequent readmissions: the influence of condition, access to services and patient choice.

BACKGROUND: People use emergency department services for a wide variety of health complaints, many of which could be handled outside hospitals. Many frequent readmissions are due to problems with chronic disease and are preventable. We postulated that patient related factors such as the type of condition, demographic factors, access to alternative services outside hospitals and patient preference for hospital or non-hospital services would influence readmissions for chronic disease. This study aimed to explore the link between frequent readmissions in chronic disease and these patient related factors. METHODS: A retrospective analysis was performed on emergency department data collected from a regional hospital in NSW Australia in 2008. Frequently readmitted patients were defined as those with three or more admissions in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on readmissions using multivariate analysis. RESULTS: The emergency department received about 20,000 presentations a year involving some 16,000 patients. Most patients (80%) presented only once. In 2008 one hundred and forty four patients were readmitted three or more times in a year. About 20% of all presentations resulted in an admission. Frequently readmitted patients were more likely to be older, have an urgent Triage classification, present with an unplanned returned visit and have a diagnosis of neurosis, chronic obstructive pulmonary disease, dyspnoea or chronic heart failure. The chronic ambulatory care sensitive conditions were strongly associated with frequent readmissions. Frequent readmissions were unrelated to gender, time, day or season of presentation or country of birth. CONCLUSIONS: Multivariate analysis of routinely collected hospital data identified that the factors associated with frequent readmission include the type of condition, urgency, unplanned return visit and age. Interventions to improve patient uptake of chronic disease management services and improving the availability of alternative non-hospital services should reduce the readmission rate in chronic disease patients.

Diagnosing asthma in adults in primary care: a qualitative study of Australian GPs' experiences.

AIM: To explore what difficulties are faced by general practitioners (GPs) when trying to make a diagnosis of asthma in adults, and whether there are patient characteristics that influence this process. METHODS: A qualitative study in which three focus group discussions were conducted with 18 GPs. RESULTS: GPs were confident with the components needed to confirm a diagnosis of asthma but not with the use of spirometry. GPs said that time was an important factor - time to undertake the tests in their practice, and time to persuade the patient to engage in the diagnostic process including follow-up visits. Patients who were less willing to engage in this process were likely to be treated symptomatically. CONCLUSION: Continuity of care is important. A diagnosis of asthma seems to be more likely in patients with an ongoing relationship with their GP where both are willing to engage in the diagnostic process.

Feasibility and efficacy of COPD case finding by practice nurses.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of disability, hospital admission and premature mortality, but is often undiagnosed. This study assessed the effectiveness, feasibility and acceptability of COPD case finding by practice nurses performing spirometry on patients identified as being at risk of developing COPD. METHODS: Practice nurses were trained in spirometry. From four general practices, 1010 patients were identified who were aged 40-80 years and current or ex-smokers. Four hundred were randomised to receive a written invitation to attend a case finding appointment with the practice nurse, including spirometry. RESULTS: Seventy-nine patients attended, 16 (20.3% of attendees) had COPD diagnosed on spirometry; practice nurses correctly identified 10 of the 16, but also incorrectly identified a further six patients as having COPD. One patient in the usual care group was diagnosed with COPD, but this was not confirmed on spirometry. DISCUSSION: This study confirmed that COPD is underdiagnosed, with 20% of those at risk and attending for screening having COPD. The search strategy successfully identified patients at risk. Further training in spirometry would be required for practice nurses to increase the accuracy of the diagnoses. The opportunity cost would require consideration. The acceptability to patients is also an issue, this may be related to the recruitment method or the intervention. This study also does not answer whether earlier diagnosis in these patients leads to any change in outcomes.

Feasibility of the PHYZ X 2U program: a mobile and cloud-based outreach service to improve chronic disease outcomes in underserviced rural communities.

Chronic disease is prevalent in rural communities, but access to health care is limited. Allied health intervention, incorporating behaviour change and exercise, may improve health outcomes. PHYZ X 2U is a new service delivery model incorporating face-to-face consultations via a mobile clinic and remote health coaching, delivered by physiotherapy and exercise physiology clinicians and university students on clinical placement, to provide exercise programs to people living with chronic disease in rural New South Wales, Australia. This pilot study evaluated the feasibility and acceptability of PHYZ X 2U by evaluating participants' goal attainment, exercise, quality of life and behaviour change following participation in the 12-week program, and amount of health coaching received. Sixty-two participants with one or more chronic diseases set a total of 123 goals. Thirty-nine (63%) participants completed the program, with 59% of these achieving their goals and 43% progressing in their attitudes and behaviour towards exercise. Weekly exercise increased by 1h following program participation (P=0.02), but quality of life remained unchanged (P=0.24). Participants who completed the program received more health coaching than those lost to follow up. PHYZ X 2U can increase access to allied health for people with chronic disease living in rural and remote areas. Refining the service to maximise program adherence and optimally manage a broad range of chronic diseases is required.