Inter-relationships among key reproductive health indicators in sub-Saharan Africa focusing on the central role of maternal literacy.

BACKGROUND: Indicators of reproductive health (RH) are expected to be both inter-related and associated with key social determinants. As the provision of RH services is usually integrated, the effort to improve one RH component should influence the other components. However, there is a lack of evidence-based models demonstrating the inter-relationships. The purpose of this study was to examine the inter-relationships among key RH indicators and their relationship with women's literacy in sub-Saharan Africa (SSA). METHODS: Data were sourced from the most recent demographic and health survey conducted between 2010 and 2016 in 391 provinces of 29 SSA countries. We examined seven RH indicators along with women's literacy. The unit of analysis was at the provincial level. Structural equation modelling was used to examine the strength of relationships among these indicators and with women's literacy, using the total standardized effect sizes. Significance tests and 95% confidence intervals (CIs) for these effects were calculated using a bias-corrected bootstrap method. RESULTS: RH indicators are strongly interrelated and are associated with women's literacy. The strongest relationship is observed between women's literacy rate and the contraception prevalence rate, with a total standardized effect size of 0.79 (95% CI 0.74-0.83). The model of inter-relationships developed in this study may guide the design, implementation and evaluation of RH policies and programmes. CONCLUSIONS: The key challenge in reducing fertility in SSA is to reduce people fertility desire. This could mainly be addressed by enhancing integrated approaches especially between the education and health sectors.

Impact of national guidelines on use of BRCA1/2 germline testing, risk management advice given to women with pathogenic BRCA1/2 variants and uptake of advice.

BACKGROUND: This nationwide study assessed the impact of nationally agreed cancer genetics guidelines on use of BRCA1/2 germline testing, risk management advice given by health professionals to women with pathogenic BRCA1/2 variants and uptake of such advice by patients. METHODS: Clinic files of 883 women who had initial proband screens for BRCA1/2 pathogenic variants at 12 familial cancer clinics between July 2008-July 2009 (i.e. before guideline release), July 2010-July 2011 and July 2012-July 2013 (both after guideline release) were audited to determine reason given for genetic testing. Separately, the clinic files of 599 female carriers without a personal history of breast/ovarian cancer who underwent BRCA1/2 predictive genetic testing and received their results pre- and post-guideline were audited to ascertain the risk management advice given by health professionals. Carriers included in this audit were invited to participate in a telephone interview to assess uptake of advice, and 329 agreed to participate. RESULTS: There were no significant changes in the percentages of tested patients meeting at least one published indication for genetic testing - 79, 77 and 78% of files met criteria before guideline, and two-, and four-years post-guideline, respectively (χ = 0.25, p = 0.88). Rates of documentation of post-test risk management advice as per guidelines increased significantly from pre- to post-guideline for 6/9 risk management strategies. The strategies with the highest compliance amongst carriers or awareness post-release of guidelines were annual magnetic resonance imaging plus mammography in women 30-50 years (97%) and annual mammography in women > 50 years (92%). Of women aged over 40 years, 41% had a risk-reducing bilateral mastectomy. Amongst women aged > 40 years, 75% had a risk-reducing salpingo-oophorectomy. Amongst women who had not had a risk-reducing bilateral mastectomy, only 6% took risk-reducing medication. Fear of side-effects was cited as the main reasons for not taking these medicines by 73% of women. CONCLUSIONS: Guidelines did not change the percentages of tested patients meeting genetic testing criteria but improved documentation of risk management advice by health professionals. Effective approaches to enhance compliance with guidelines are needed to improve risk management and quality of care.

Factors affecting procurement of wound care products: a qualitative study of hospital managers and clinicians.

Objective To identify factors that influence procurement and disinvestment decisions for wound care products in the acute care setting. Methods A qualitative descriptive study was undertaken. Eighteen face-to-face semi-structured interviews were conducted with purposively sampled senior clinical and non-clinical managers from three Australian acute care hospitals with responsibility for consumables procurement and disinvestment decisions. Data were coded and analysed thematically. Results Three main themes (Systems and triggers, Evidence-free zone, Getting the governance right) with sub-themes were identified that reflect that: (1) procurement processes were often ad hoc and workarounds common. Disinvestment was poorly understood and opportunities were missed to reduce use of low value products ; (2) product selection was commonly based on clinician preference, contractual obligations and information from industry representatives; and (3) improved evidence-based governance and processes are needed to connect procurement and disinvestment decisions and to minimise the influences of clinician preference and industry representatives on product selection. Conclusions Systematic and evidence-based approaches are needed to strengthen procurement and disinvestment decisions related to consumables such as wound care products and to minimise the purchasing of low-value products Decision-making frameworks should consider cost and clinical effectiveness and enable the identification of opportunities to disinvest from low-value products. What is known about the topic? High volume-low unit cost healthcare consumables such as wound care products are a major component of healthcare expenditure. Disinvestment from low-value wound care products has potential to improve patient outcomes and optimise health resources. What does this paper add? Disinvestment was poorly understood and considered in isolation from procurement decisions. Procurement decisions were rarely informed by research evidence, with clinicians exercising considerable freedom to make purchasing decisions based on product preference and industry information. Frameworks and guidelines are needed to guide procurement and disinvestment decision-making for wound care products. What are the implications for practitioners? New models for procurement and disinvestment decision-making for wound care products could help to strengthen decision-making processes, facilitate evidence-based product choices and also prompt consideration of removal of low-value products.

Translating research into practice: outcomes from the Healthy Living after Cancer partnership project.

BACKGROUND: Healthy Living after Cancer (HLaC) was a national dissemination and implementation study of an evidence-based lifestyle intervention for cancer survivors. The program was imbedded into existing telephone cancer information and support services delivered by Australian state-based Cancer Councils (CC). We report here the reach, effectiveness, adoption, implementation, and maintenance of the program. METHODS: In this phase IV study (single-group, pre-post design) participants - survivors of any type of cancer, following treatment with curative intent - received up to 12 nurse/allied health professional-led telephone health coaching calls over 6 months. Intervention delivery was grounded in motivational interviewing, with emphasis on evidence-based behaviour change strategies. Using the RE-AIM evaluation framework, primary outcomes were reach, indicators of program adoption, implementation, costs and maintenance. Secondary (effectiveness) outcomes were participant-reported anthropometric, behavioural and psychosocial variables including: weight; physical activity; dietary intake; quality-of-life; treatment side-effects; distress; and fear of cancer recurrence and participant satisfaction. Changes were evaluated using linear mixed models, including terms for timepoint (0/6 months), strata (Cancer Council), and timepoint x strata. RESULTS: Four of 5 CCs approached participated in the study. In total, 1183 cancer survivors were referred (mostly via calls to the Cancer Council telephone information service). Of these, 90.4% were eligible and 88.7% (n = 791) of those eligible consented to participate. Retention rate was 63.4%. Participants were mostly female (88%), aged 57 years and were overweight (BMI = 28.8 ± 6.5 kg/m2). Improvements in all participant-reported outcomes (standardised effect sizes of 0.1 to 0.6) were observed (p < 0.001). The program delivery costs were on average AU$427 (US$296) per referred cancer survivor. CONCLUSIONS: This telephone-delivered lifestyle intervention, which was feasibly implemented by Cancer Councils, led to meaningful and statistically significant improvements in cancer survivors' health and quality-of-life at a relatively low cost. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12615000882527 (registered on 24/08/2015).

Sex disparities in the assessment and outcomes of chest pain presentations in emergency departments.

OBJECTIVE: To determine whether sex differences exist in the triage, management and outcomes associated with non-traumatic chest pain presentations in the emergency department (ED). METHODS: All adults (≥18 years) with non-traumatic chest pain presentations to three EDs in Melbourne, Australia between 2009 and 2013 were retrospectively analysed. Data sources included routinely collected hospital databases. Triage scoring of the urgency of presentation, time to medical examination, cardiac troponin testing, admission to specialised care units, and in-ED and in-hospital mortality were each modelled using the generalised estimating equations approach. RESULTS: Overall 54 138 patients (48.7% women) presented with chest pain, contributing to 76 216 presentations, of which 26 282 (34.5%) were cardiac. In multivariable analyses, compared with men, women were 18% less likely to be allocated an urgency of 'immediate review' or 'within 10 min review' (OR=0.82, 95% CI 0.79 to 0.85), 16% less likely to be examined within the first hour of arrival to the ED by an emergency physician (0.84, 0.81 to 0.87), 20% less likely to have a troponin test performed (0.80, 0.77 to 0.83), 36% less likely to be admitted to a specialised care unit (0.64, 0.61 to 0.68), and 35% (p=0.039) and 36% (p=0.002) more likely to die in the ED and in the hospital, respectively. CONCLUSIONS: In the ED, systemic sex bias, to the detriment of women, exists in the early management and treatment of non-traumatic chest pain. Future studies that identify the drivers explaining why women presenting with chest pain are disadvantaged in terms of care, relative to men, are warranted.

Socioeconomic gradients in admission to coronary or intensive care units among Australians presenting with non-traumatic chest pain in emergency departments.

BACKGROUND: Socioeconomic inequalities in cardiovascular morbidity have been previously reported showing direct associations between socioeconomic disadvantage and worse health outcomes. However, disagreement remains regarding the strength of the direct associations. The main objective of this panel design was to inspect socioeconomic gradients in admission to a coronary care unit (CCU) or an intensive care unit (ICU) among adult patients presenting with non-traumatic chest pain in three acute-care public hospitals in Victoria, Australia, during 2009-2013. METHODS: Consecutive adults aged 18 or over presenting with chest pain in three emergency departments (ED) in Victoria, Australia during the five-year study period were eligible to participate. A relative index of inequality of socioeconomic status (SES) was estimated based on residential postcode socioeconomic index for areas (SEIFA) disadvantage scores. Admission to specialised care units over repeated presentations was modelled using a multivariable Generalized Estimating Equations approach that accounted for various socio-demographic and clinical variables. RESULTS: Non-traumatic chest pain accounted for 10% of all presentations in the emergency departments (ED). A total of 53,177 individuals presented during the study period, with 22.5% presenting more than once. Of all patients, 17,579 (33.1%) were hospitalised over time, of whom 8584 (48.8%) were treated in a specialised care unit. Female sex was independently associated with fewer admissions to CCU / ICU, whereas, a dose-response effect of socioeconomic disadvantage and admission to CCU / ICU was found, with risk of admission increasing incrementally as SES declined. Patients coming from the lowest SES locations were 27% more likely to be admitted to these units compared with those coming from the least disadvantaged locations, p <  0.001. Men were significantly more likely to be admitted to such units than similarly affected and aged women among those diagnosed with angina pectoris, arrhythmia, myocardial infarction, heart failure, chest pain, and general signs and symptoms. CONCLUSIONS: This study is the first to report socioeconomic gradients in admission to CCU / ICU in patients presenting with chest pain showing a dose-response effect. Our findings suggest increased cardiovascular morbidity as socioeconomic disadvantage increases.

Disparities in maternal health services in sub-Saharan Africa.

OBJECTIVES: To examine the progress of and disparities in the provision of key maternal health services in the sub-Saharan Africa (SSA) region. METHODS: A time-trend analysis of disparities in antenatal care (ANC) and skilled birth attendance (SBA) coverage in SSA over the last 25 years was conducted. The average values of each country's 5-year period data were used for analysis. Absolute and relative disparities were examined by time period, economic class, geographic group and clusters. Analysis of variance was used to compare progresses in coverage across time. RESULTS: Regional median ANC coverage and SBA increased by 8% points and 15% points, respectively, during the 25-year period. The rank score of SBA has shown significant improvement only in the recent period. A 33.3% disparity between ANC and SBA was observed in the most recent period. The relative disparity by economic class and cluster was higher for SBA than ANC coverage. CONCLUSIONS: The region showed improvement in both indicators across time. Regional disparity in ANC narrowed down while that of SBA remained high. These were mainly associated with economic class and cluster of countries.

Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention: QASC Trial (Quality in Acute Stroke Care) Follow-Up.

BACKGROUND AND PURPOSE: Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005-2010). We now examine long-term all-cause mortality. METHODS: Mortality was ascertained using Australia's National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber-White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates. RESULTS: One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58-1.07; P=0.13; adjusted HR, 0.77; 95% CI, 0.59-0.99; P=0.045). Older age (75-84 years; HR, 4.9; 95% CI, 2.8-8.7; P<0.001) and increasing stroke severity (HR, 1.5; 95% CI, 1.3-1.9; P<0.001) were associated with increased mortality, while being married (HR, 0.70; 95% CI, 0.49-0.99; P=0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths. CONCLUSIONS: Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care. CLINICAL TRIAL REGISTRATION: URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000563369.

Factors Influencing Knowledge, Food Safety Practices and Food Preferences During Warm Weather of Salmonella and Campylobacter Cases in South Australia.

OBJECTIVE: To assess food safety practices, food shopping preferences, and eating behaviors of people diagnosed with Salmonella or Campylobacter infection in the warm seasons, and to identify socioeconomic factors associated with behavior and practices. METHODS: A cross-sectional survey was conducted among Salmonella and Campylobacter cases with onset of illness from January 1 to March 31, 2013. Multivariable logistic regression analyses examined relationships between socioeconomic position and food safety knowledge and practices, shopping and food preferences, and preferences, perceptions, and knowledge about food safety information on warm days. RESULTS: Respondents in our study engaged in unsafe personal and food hygiene practices. They also carried out unsafe food preparation practices, and had poor knowledge of foods associated with an increased risk of foodborne illness. Socioeconomic position did not influence food safety practices. We found that people's reported eating behaviors and food preferences were influenced by warm weather. CONCLUSIONS: Our study has explored preferences and practices related to food safety in the warm season months. This is important given that warmer ambient temperatures are projected to rise, both globally and in Australia, and will have a substantial effect on the burden of infectious gastroenteritis including foodborne disease. Our results provide information about modifiable behaviors for the prevention of foodborne illness in the household in the warm weather and the need for information to be disseminated across the general population. An understanding of the knowledge and factors associated with human behavior during warmer weather is critical for public health interventions on foodborne prevention.

Factors Associated with Disability in Rural Bangladesh: Bangladesh Population-Based Diabetes and Eye Study (BPDES).

BACKGROUND: To assess factors associated with disability in a rural district of Bangladesh. METHODS: Using a population-based systematic sampling technique, data were collected from 3104 adults aged ≥ 30 years from the Banshgram union of Narail district. Data collected included an interviewer administered questionnaire to report physical disabilities including impairment that prevents engagement with paid work, visual, hearing, and mobility as well as mental disabilities. Socio-demographic and anthropometric factors including educational attainment and body mass index, as well as clinical factors such as blood pressure, and fasting blood glucose were also collected. Binary and multinomial logistic regression techniques were used to explore the association of various socio-demographic and clinical factors with disability. RESULTS: The mean (SD), minimum and maximum ages of the participants were 51 (12), 30 and 89 years. Of total participants, 65% were female. The prevalence of disability varied from 29.1% for visual impairment (highest) to 16.5% for hearing, 14.7% for movement difficulties and 1.6% (lowest) for any other disability that prevented engagement with paid work. Overall, the prevalence of a single disability was 28.6% and that of two or more disabilities was 14.7%. Older age, gender (female), lower socio-economic status (SES), and hypertension were associated with a higher prevalence of most of the disability components. The prevalence of hearing problems (24.5% vs. 13.3%, p<0.001) and movement difficulties (24.9% vs. 13.0%, p<0.001) was significantly higher among lower-income participants than their higher-income counterparts after controlling for age. Prevalence of visual impairment (54.6% vs. 9.2%, p<0.001), hearing (32.2% vs. 6.7%, p<0.001) and movement difficulties (29.2% vs. 5.5%, p<0.001) were significantly higher in people of aged 60 years or older than those aged 30-34 years. After multivariate adjustment, the prevalence of single disability (prevalence risk ratio [PRR] 1.25, 95% CI: 1.09-1.42, p<0.001), and multiple disabilities (PRR 1.41, 95% CI 1.14-1.73, p<0.001) was higher among females than males. The prevalence of single disability and multiple disabilities was respectively 21% (PRR 1.21, 95% CI: 1.02-1.42, p<0.001) and 88% (PRR 1.88, 95% CI: 1.38-2.54, p<0.001) higher among participants with low educational attainment (primary level or less) than those with at least a secondary level of education. CONCLUSIONS: In rural Bangladesh, the prevalence of disability is high. Public health programs should target those of low SES, older age, and female participants and aim to provide necessary supports in order to bridge disability-related inequities.

Depression and Anxiety Outcomes Associated with Failed Assisted Reproductive Technologies: A Systematic Review and Meta-Analysis.

OBJECTIVE: Our study examined the psychological outcomes associated with failed ART treatment outcomes in men and women. SEARCH STRATEGY: A systematic search for studies published between January 1980 and August 2015 was performed across seven electronic databases. INCLUSION CRITERIA: Studies were included if they contained data on psychosocial outcomes taken pre and post ART treatment. DATA EXTRACTION AND SYNTHESIS: A standardised form was used to extract data and was verified by two independent reviewers. Studies were meta-analysed to determine the association of depression and anxiety with ART treatment outcomes. Narrative synthesis identified factors to explain variations in the size and directions of effects and relationships explored within and between the studies. MAIN RESULTS: Both depression and anxiety increased after a ART treatment failure with an overall pooled standardised mean difference (SMD) of 0.41 (95% CI: 0.27, 0.55) for depression and 0.21 (95% CI: 0.13, 0.29) for anxiety. In contrast, depression decreased after a successful treatment, SMD of -0.24 (95% CI: -0.37,-0.11). Both depression and anxiety decreased as time passed from ART procedure. Nonetheless, these remained higher than baseline measures in the group with the failed outcome even six months after the procedure. Studies included in the narrative synthesis also confirmed an association with negative psychological outcomes in relation to marital satisfaction and general well-being following treatment failure. CONCLUSION: Linking ART failure and psychosocial outcomes may elucidate the experience of treatment subgroups, influence deliberations around recommendations for resource allocation and health policy and guide patient and clinician decision making.

Experiences of nurse practitioners and medical practitioners working in collaborative practice models in primary healthcare in Australia - a multiple case study using mixed methods.

BACKGROUND: In 2010 policy changes were introduced to the Australian healthcare system that granted nurse practitioners access to the public health insurance scheme (Medicare) subject to a collaborative arrangement with a medical practitioner. These changes facilitated nurse practitioner practice in primary healthcare settings. This study investigated the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models. METHODS: A multiple case study of five primary healthcare sites was undertaken, applying mixed methods research. Six nurse practitioners, 13 medical practitioners and three practice managers participated in the study. Data were collected through direct observations, documents and semi-structured interviews as well as questionnaires including validated scales to measure the level of collaboration, satisfaction with collaboration and beliefs in the benefits of collaboration. Thematic analysis was undertaken for qualitative data from interviews, observations and documents, followed by deductive analysis whereby thematic categories were compared to two theoretical models of collaboration. Questionnaire responses were summarised using descriptive statistics. RESULTS: Using the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners' and medical practitioners' adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals. CONCLUSIONS: Findings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions. However, strategic support from healthcare reform decision-makers is needed to strengthen nurse practitioner positions and ensure the sustainability of collaborative practice models in primary healthcare.

Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting.

BACKGROUND: Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated. METHODS: Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated. RESULTS: Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %. CONCLUSIONS: Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

Heatwaves differentially affect risk of Salmonella serotypes.

OBJECTIVES: Given increasing frequency of heatwaves and growing public health concerns associated with foodborne disease, we examined the relationship between heatwaves and salmonellosis in Adelaide, Australia. METHODS: Poisson regression analysis with Generalised Estimating Equations was used to estimate the effect of heatwaves and the impact of intensity, duration and timing on salmonellosis and specific serotypes notified from 1990 to 2012. Distributed lag non-linear models were applied to assess the non-linear and delayed effects of temperature during heatwaves on Salmonella cases. RESULTS: Salmonella typhimurium PT135 notifications were sensitive to the effects of heatwaves with a twofold (IRR 2.08, 95% CI 1.14-3.79) increase in cases relative to non-heatwave days. Heatwave intensity had a significant effect on daily counts of overall salmonellosis with a 34% increase in risk of infection (IRR 1.34, 95% CI 1.01-1.78) at >41 °C. The effects of temperature during heatwaves on Salmonella cases and serotypes were found at lags of up to 14 days. CONCLUSION: This study confirms heatwaves have a significant effect on Salmonella cases, and for the first time, identifies its impact on specific serotypes and phage types. These findings will contribute to the understanding of the impact of heatwaves on salmonellosis and provide insights that could mitigate their impact.

The utility of linked cancer registry and health administration data for describing system-wide outcomes and research: a BreastScreen example.

RATIONALE, AIMS AND OBJECTIVES: Stratification of women with screen-detected ductal carcinoma in situ (DCIS) by risk of subsequent invasive breast cancer (IBC) could assist treatment planning and selection of surveillance protocols that accord with risk. We assessed the utility of routinely collected administrative data for stratifying by IBC risk following DCIS detection in a population-based screening programme to inform ongoing surveillance protocols. METHODS: A retrospective cohort design was used, employing linked data from the South Australian breast screening programme and cancer registry. Women entered the study at screening commencement and were followed until IBC diagnosis, death or end of the study period (1 December 2010), whichever came first. Routinely collected administrative data were analyzed to identify predictors of invasive breast cancer. RESULTS: Proportional hazards regression confirmed that the DCIS cohort had an elevated risk of IBC after adjustment for relevant confounders (HR = 4.0 (95% CL 3.4, 4.8)), which accorded with previous study results. Within the DCIS cohort, conservative breast surgery and earlier year of screening commencement were both predictive of an elevated invasive breast cancer risk. CONCLUSIONS: These linked cancer registry and administrative data gave plausible estimates of IBC risk following DCIS diagnosis, but were limited in coverage of key items for further risk stratification. It is important that the research utility of administrative datasets is maximized in their design phase in collaboration with researchers.

Impact of the "Linked Evidence Approach" Method on Policies to Publicly Fund Diagnostic, Staging, and Screening Medical Tests.

Background: The linked evidence approach (LEA) is used in health technology assessment (HTA) to evaluate the clinical utility of new medical tests in the absence of direct trial evidence. Objective: To determine whether use of LEA affects decisions to publicly fund medical tests. Methods: Australian HTAs that evaluated medical tests before and after LEA was mandated (in 2005) were screened for eligibility. Data were extracted and the impact of LEA and other possible clinical predictors (selected a priori) on funding decisions was modelled. Regression diagnostics were performed to estimate model fit, model specification, and to inform model selection. The unit of analysis was per clinical indication for each new test, so analyses were adjusted for clustering. Results: 83 HTAs (for 173 clinical indications) were eligible from the 259 screened. When health policy was compared before and after 2005, there was an 11% reduction in overall positive funding decisions, including a 25% decrease in "interim" (coverage with evidence development) funding decisions. The odds of obtaining interim funding reduced by 98% (odds ratio = 0.02, 95% confidence interval = 0.0005, 0.17), but there was no change in the direction of funding decisions (odds ratio = 1.36, 95% confidence interval = 0.62, 3.01). Across both time periods, when LEA was used there was a very strong likelihood that the medical test would not receive interim funding (χ2 = 12.63, df = 1, P = 0.001). For positive funding decisions, the strongest predictors were whether or not the new test would replace an existing test and whether the available evidence was limited. Conclusions: The use of LEA did not predict the direction of funding decisions. Application of the method did predict that a "coverage with evidence development" decision was unlikely. This suggests that LEA may reduce decision-maker uncertainty.

Citizens' Perspectives on Disinvestment from Publicly Funded Pathology Tests: A Deliberative Forum.

BACKGROUND: Deliberative forums can be useful tools in policy decision making for balancing citizen voice and community values against dominant interests. OBJECTIVE: To describe the use of a deliberative forum to explore community perspectives on a complex health problem-disinvestment. METHODS: A deliberative forum of citizens was convened in Adelaide, South Australia, to develop criteria to support disinvestment from public funding of ineffective pathology tests. The case study of potential disinvestment from vitamin B12/folate pathology testing was used to shape the debate. The forum was informed by a systematic review of B12/folate pathology test effectiveness and expert testimony. RESULTS: The citizens identified seven criteria: cost of the test, potential impact on individual health/capacity to benefit, potential cost to society, public good, alternatives to testing, severity of the condition, and accuracy of the test. The participants not only saw these criteria as an interdependent network but also questioned "the authority" of policymakers to make these decisions. CONCLUSIONS: Coherence between the criteria devised by the forum and those described by an expert group was considerable, the major differences being that the citizens did not consider equity issues and the experts neglected the "cost" of social and emotional impact of disinvestment on users and the society.

Healthy Living after Cancer: a dissemination and implementation study evaluating a telephone-delivered healthy lifestyle program for cancer survivors.

BACKGROUND: Given evidence shows physical activity, a healthful diet and weight management can improve cancer outcomes and reduce chronic disease risk, the major cancer organisations and health authorities have endorsed related guidelines for cancer survivors. Despite these, and a growing evidence base on effective lifestyle interventions, there is limited uptake into survivorship care. METHODS/DESIGN: Healthy Living after Cancer (HLaC) is a national dissemination and implementation study that will evaluate the integration of an evidence-based lifestyle intervention for cancer survivors into an existing telephone cancer information and support service delivered by Australian state-based Cancer Councils. Eligible participants (adults having completed cancer treatment with curative intent) will receive 12 health coaching calls over 6 months from Cancer Council nurses/allied health professionals targeting national guidelines for physical activity, healthy eating and weight control. Using the RE-AIM evaluation framework, primary outcomes are service-level indicators of program reach, adoption, implementation/costs and maintenance, with secondary (effectiveness) outcomes of patient-reported anthropometric, behavioural and psychosocial variables collected at pre- and post-program completion. The total participant accrual target across four participating Cancer Councils is 900 over 3 years. DISCUSSION: The national scope of the project and broad inclusion of cancer survivors, alongside evaluation of service-level indicators, associated costs and patient-reported outcomes, will provide the necessary practice-based evidence needed to inform future allocation of resources to support healthy living among cancer survivors. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (ANZCTR)--ACTRN12615000882527 (registered on 24/08/2015).

Relative benefit of a stage of change approach for the prevention of musculoskeletal pain and discomfort: a cluster randomised trial.

OBJECTIVES: To examine the benefit of a psychological Stage of Change (SOC) approach, relative to standard ergonomics advice, for the prevention of work-related musculoskeletal pain and discomfort (MSPD). METHODS: A cluster randomised trial was conducted in South Australia across a broad range of workplaces. Repeated face-to-face interviews were conducted onsite to assess MSPD, safety climate, job satisfaction and other factors. Changes in MSPD across intervention groups and time were investigated using Generalised Estimating Equation (GEE) methods. RESULTS: 25 workgroups (involving 242 workers) were randomly allocated to either a standard intervention or an intervention tailored according to SOC. The prevalence of MSPD increased for both groups, but was only significant for the standard group, in respect of lower back MSPD. Workers receiving tailored interventions were 60% less likely to experience lower back MSPD. After adjusting for age, gender and job satisfaction, it was found that company safety climate and length of employment were significantly correlated to the time-intervention effect. There was no correlation with workload. CONCLUSIONS: Compared with standard ergonomics advice to management, there was evidence of a benefit of stage-matched intervention for MSPD prevention, particularly for low back pain. Organisational safety climate should be taken into account when planning prevention programmes.

Informing disinvestment with limited evidence: cobalamin deficiency in the fatigued.

OBJECTIVES: Health technology reassessment and disinvestment can be difficult due to uncertainties regarding available evidence. Pathology testing to investigate cobalamin (vitamin B12) deficiency is a strong case in point. We conducted a 3-month economic evaluation of five strategies for diagnosing and treating cobalamin deficiency in adult patients hypothetically presenting with new unexplained fatigue in the primary care setting. The first consultation per patient was considered. Screening tests other than serum cobalamin were not included. METHODS: A cost-effectiveness analysis was undertaken using a decision tree to represent the diagnostic / treatment pathways, with relevant cost and utility scores assigned to different stages in the evaluation process. Input parameter values were estimated from published evidence, supplemented by expert opinion, with sensitivity analysis undertaken to represent parameter uncertainty. RESULTS: Ordering serum vitamin B12 to assess cobalamin deficiency among patients with unexplained fatigue was not cost-effective in any patient population, irrespective of pretest prevalence of this deficiency. For patients with a pretest prevalence above 1 percent, treating all with oral vitamin B12 supplements without testing was most cost-effective, whereas watchful waiting with symptoms monitoring was most cost-effective for patients with lower pretest prevalence probabilities. CONCLUSIONS: Substantial evidence gaps exist for parameter estimation: questionable cobalamin deficiency levels in the fatigued; debatable treatment methods; unknown natural history of the condition. Despite this, we reveal a robust path for disinvestment decision making in the face of a paradox between the evidence required to inform disinvestment compared with its paucity in informing initial funding decisions.