GP awareness, practice, knowledge and confidence: evaluation of the first nation-wide dementia-focused continuing medical education program in Australia.

BACKGROUND: Dementia is under-diagnosed in primary care. Timely diagnosis and care management improve outcomes for patients and caregivers. This research evaluated the effectiveness of a nationwide Continuing Medical Education (CME) program to enhance dementia-related awareness, practice, knowledge and confidence of general practitioners (GPs) in Australia. METHODS: Data were collected from self-report surveys by GPs who participated in an accredited CME program face-to-face or online; program evaluations from GPs; and process evaluations from workshop facilitators. CME participants completed surveys at one or more time-points (pre-, post-program, six to 9 months follow-up) between 2015 and 2017. Paired samples t-test was used to determine difference in mean outcome scores (self-reported change in awareness, knowledge, confidence, practice) between time-points. Multivariable regression analyses were used to investigate associations between respondent characteristics and key variables. Qualitative feedback was analysed thematically. RESULTS: Of 1352 GPs who completed a survey at one or more time-points (pre: 1303; post: 1017; follow-up: 138), mean scores increased between pre-CME and post-program for awareness (Mpost-pre = 0.9, p <  0.0005), practice-related items (Mpost-pre = 1.3, p <  0.0005), knowledge (Mpost-pre = 2.2, p <  0.0005), confidence (Mpost-pre = 2.1, p <  0.0005). Significant increases were seen in all four outcomes for GPs who completed these surveys at both pre- and follow-up time-points. Male participants and those who had practised for five or more years showed greater change in knowledge and confidence. Age, years in practice, and education delivery method significantly predicted post-program knowledge and confidence. Most respondents who completed additional program evaluations (> 90%) rated the training as relevant to their practice. These participants, and facilitators who completed process evaluations, suggested adding more content addressing patient capacity and legal issues, locality-specific specialist and support services, case studies and videos to illustrate concepts. CONCLUSIONS: The sustainability of change in key elements relating to health professionals' dementia awareness, knowledge and confidence indicated that dementia CME programs may contribute to improving capacity to provide timely dementia diagnosis and management in general practice. Low follow-up response rates warrant cautious interpretation of results. Dementia CME should be adopted in other contexts and updated as more research becomes available.

A training program for primary health care nurses on timely diagnosis and management of dementia in general practice: An evaluation study.

BACKGROUND: Primary health care nurses can play an important role in assisting the diagnosis and management of dementia. This study describes the evaluation outcome of a training program developed on the 'Four Steps to Building Dementia Practice in Primary Care'. OBJECTIVE: To evaluate a training program for primary health care nurses by assessing change in current practice and future intention; and their knowledge, confidence, and perceived importance about dementia diagnosis and management. DESIGN: A longitudinal survey. Participants were surveyed at three time points: pre-training, immediately post-training and six months (+/- 3 months) following their training. SETTING: All states and territories in Australia. PARTICIPANTS: Primary health care nurses (n = 1,290). METHODS: A face-to-face and online training program on timely diagnosis and management of dementia was offered to primary health care nurses. A questionnaire was administered face-to-face and online to assess whether certain processes and services were 'currently in practice', 'working towards', or 'not in current practice' in their primary care facility. Three 10-point Likert scales were created to assess self-perceived levels of importance, knowledge and confidence about the diagnosis and management of dementia. A paired t-test was used to examine the differences between (a) post and pre-scores, and (b) follow-up and post scores. Linear regressions were used to identify the significant factors associated with pre-training scores for importance, confidence and knowledge. RESULTS: Of 1290 primary health care nurses who participated in the training, 471 attended face-to-face and 819 participated online. Participants demonstrated improvements in all items in all four steps of the survey, with considerably higher improvement in the face-to-face mode. The average post-training score was significantly higher than the pre-training score for perceived importance, knowledge and confidence. The average follow-up score was significantly higher than the post-training score for perceived knowledge and confidence but not for perceived importance. Primary health care nurses who had 20 or more years of experience reported significantly more knowledge in attending patients with dementia than those with less than five years of experience (0.56, 95% CI: 0.11-1.01). CONCLUSIONS: With a growing ageing population, the demand for dementia care is rising. Primary health care nurses can lead practice change and promote the timely diagnosis and management of dementia in general practice. Training programs of this kind that build knowledge, confidence, awareness and skills should be made available to the primary care nursing workforce. Further research is recommended to examine the translation of this training outcome into practice.

Failure to access prescribed pharmaceuticals by older patients with chronic conditions.

Objective Medication adherence is a significant public health concern. Australian studies of statins show patients facing the highest copayments are the least likely to be adherent. This study examined whether the association identified between adherence and costs for statins also applies to a wider group of medications prescribed for Australian patients with chronic conditions. Methods Data from 267086 participants in the Sax Institute's 45 and Up Study linked to data from the Pharmaceutical Benefits Scheme (PBS) provided by the Department of Human Services were used. Patients using angiotensin II receptor blockers, angiotensin-converting enzyme inhibitors, glitazones and bisphosphonates were identified and classified according to concessional status and whether they had access to the PBS 'safety net'. Data were analysed using mainly descriptive methods to investigate the association of adherence with cost and other selected covariates. Results Across medications, the group facing the highest copayment was least adherent. Speaking a language other than English at home and facing high levels of psychological distress were also associated with lower levels of adherence. Conclusions As for statins, the main financial determinant of adherence is cost in the form of prescribed copayments, suggesting that this may apply across many medications. What is known about the topic? Previous studies have shown patients' concern about the costs of pharmaceuticals, and more detailed studies of statins show that the lowest adherence relates to patients facing the highest copayments. What does this paper add? This paper provides support for the contention that the results found for statins broadly apply across more medications used by people with chronic conditions. What are the implications for practitioners? Although practitioners cannot affect legislated copayments, they can consider the costs of options for medications for patients with chronic conditions, especially those general patients who have not reached the safety net, and they can be aware that patients from homes where English is not spoken and patients with high levels of psychological distress are also likely to have low adherence without intervention.

Role of Cost on Failure to Access Prescribed Pharmaceuticals: The Case of Statins.

BACKGROUND: In Australia, as in many other Western countries, patient surveys suggest the costs of medicines lead to deferring or avoiding filling of prescriptions. The Australian Pharmaceutical Benefits Scheme provides approved prescription medicines at subsidised prices with relatively low patient co-payments. The Pharmaceutical Benefits Scheme defines patient co-payment levels per script depending on whether patients are "concessional" (holding prescribed pension or other government concession cards) or "general", and whether they have reached a safety net defined by total out-of-pocket costs for Pharmaceutical Benefits Scheme-approved medicines. OBJECTIVE: The purpose of this study was to explore the impact of costs on adherence to statins in this relatively low-cost environment. METHODS: Using data from a large-scale survey of older Australians in the state of New South Wales linked to administrative data from the national medical and pharmaceutical insurance schemes, we explore the relationships between adherence to medication regimes for statins and out-of-pocket costs of prescribed pharmaceuticals, income, other health costs, and a wide set of demographic and socio-economic control variables using both descriptive analysis and logistic regressions. RESULTS: Within the general non-safety net group, which has the highest co-payment, those with lowest income have the lowest adherence, suggesting that the general safety threshold may be set at a level that forms a major barrier to statin adherence. This is reinforced by over 75% of those who were not adherent before reaching the safety net threshold becoming adherent after reaching the safety net with its lower co-payments. CONCLUSION: The main financial determinant of adherence is the concessional/general and safety net category of the patient, which means the main determinant is the level of co-payment.

Worry and time: the unseen costs of informal care.

OBJECTIVES: The objective of this study is to examine the experiences of informal carers in terms of how their time spent caring is related to worry. Is worry about a care recipient a care practice, and if so, to what extent it can be understood temporally? METHODS: Classical phenomenology underpinned this study. Three qualitative studies of people living with chronic illness in Australia were conducted between 2009 and 2013. Semi-structured interviews were conducted. Interviews were audio recorded and transcribed verbatim. Phenomenological thematic analysis of the data was undertaken. RESULTS: Twenty-five informal carers participated. The findings pivot around three interconnected themes: time, worry and cost. Worry was identified as a temporally bound unseen cost to carers that informs carer identity irrespective of culture, ethnicity, or social status. DISCUSSION: Worry is a practice that most carers report engaging in and it is one that comes with a temporal cost-it keeps people busy looking after the needs of others during the day and it keeps some people awake when they would rather be sleeping. Worry takes time and effort, it informs people's construction of their own sense of self, motivates acts of care, and informs carers' imaginings of what their future and that of their loved one(s) may entail.

Time to manage: patient strategies for coping with an absence of care coordination and continuity.

This paper examines how people with chronic illnesses respond to absences of continuity and coordination of care. Little work has been done on how the ill person might mitigate flaws in a less than optimal system. Our qualitative research, carried out among 91 participants in Australia, reveals that people with chronic illnesses create strategies to facilitate the management of their care. These strategies included efforts to improve communication between themselves and their health care practitioners; keeping personal up-to-date medication lists; and generating their own specific management plans. While we do not submit that it is patients' responsibility to attend to gaps in the health system, our data suggests that chronically ill people can, in and through such strategies, exert a measure of agency over their own care; making it effectively more continuous and coordinated. Participants crafted strategies according to the particular social and bodily rhythms that their ongoing illnesses had lent to their lives. Our analysis advances the view that the ill body itself is capable of enfolding the health system into the rhythms of illness - rather than the ill body always fitting into the overarching structural tempo. This entails an agent-centric view of time in illness experience. A Virtual Abstract of this paper can be found at: https://youtu.be/UwbxlEJOTx8.

Does it matter who organises your health care?

BACKGROUND: As the prevalence of long-term and multimorbid conditions is increasing, patients increasingly require consultations with multiple health care professionals and coordination of their care needs. METHODS: This study is based on a 2011 survey of older Australians which draws on sub-populations of people with diabetes aged 50 years or over, people with chronic obstructive pulmonary disease, and members of Nationals Seniors Australia. We develop a composite coordination measure and examine differences in the measure with different care coordination indicators using both descriptive and regression methods. Three categories of respondent-perceived care organisers are used: health care professionals; "no one"; and patients, their partner, relative or friend. RESULTS: Of the 2,540 survey respondents (an overall response rate of 24%), 1,865 provided information on who organised their health care, and composite coordination measures were calculated for 1,614. Multivariate analysis showed the composite score was highest where a health care professional coordinated care, followed by care organised by self or a carer, and then the group reporting no organiser. CONCLUSION: In moving towards care coordination there are opportunities to improve the care coordination process itself, and the key enablers to improving care coordination appear to be the availability and communication of clinical information and the role of the clinical team.

Time spent on health-related activities by senior Australians with chronic diseases: what is the role of multimorbidity and comorbidity?

OBJECTIVE: To examine the effect of various morbidity clusters of chronic diseases on health-related time use and to explore factors associated with heavy time burden (more than 30 hours/month) of health-related activities. METHODS: Using a national survey, data were collected from 2,540 senior Australians. Natural clusters were identified using cluster analysis and clinical clusters using clinical expert opinion. We undertook a set of linear regressions to model people's time use, and logistic regressions to model heavy time burden. RESULTS: Time use increases with the number of chronic diseases. Six of the 12 diseases are significantly associated with higher time use, with the highest effect for diabetes followed by depression; 18% reported a heavy time burden, with diabetes again being the most significant disease. Clusters and dominant comorbid groupings do not contribute to predicting time use or time burden. CONCLUSIONS: Total number of diseases and specific diseases are useful determinants of time use and heavy time burden. Dominant groupings and disease clusters do not predict time use. IMPLICATIONS: In considering time demands on patients and the need for care co-ordination, care providers need to be aware of how many and what specific diseases the patient faces.

Affordability of out-of-pocket health care expenses among older Australians.

Australia has universal health insurance, and provides price concessions on health care and prescription pharmaceuticals through government subsidies. However Australia ranks among the highest OECD nations for out-of-pocket health care spending. With high prevalence of multimorbidity (27% aged 65 and over have 2 or more long-term health conditions) older Australians may face a severe financial burden from out-of-pocket health expenses. We surveyed 4574 members of National Seniors Australia aged 50 years or more on their inability to pay out-of-pocket health-related expenses across categories of medical consultations and tests, medications, dental appointments, allied health appointments (e.g. physiotherapy, podiatry) and transport to medical appointments or tests. Almost 4% of those surveyed were unable to afford out-of-pocket costs in at least one category of health care expenses in the previous 3 months. The odds of being unable to afford out-of-pocket medical costs increased with the number of chronic medical conditions (3 conditions: OR 3.05, 95% CI 1.17-6.30; 4 or more conditions: OR 3.45, 95% CI 1.34-7.28, compared with no chronic medical conditions). Despite Australia's universal health insurance, and safety nets for medical and pharmaceutical contributions, older Australians with multiple chronic conditions are at risk of being unable to afford out-of-pocket health care expenses.

Improving coordination through information continuity: a framework for translational research.

BACKGROUND: There is good evidence that coordination can have beneficial impacts on patient care and outcomes but the mechanisms by which coordination is to be achieved are poorly understood and rarely identified in relevant policies. One approach suggests that continuity of information is a key element but research is yet to provide guidance on how to optimise coordination through improving continuity in healthcare settings. DISCUSSION: In this paper we report on the development of a conceptual framework of information continuity in care coordination. We drew on evidence from systematic reviews of coordination and empirical studies on information use in integrated care models to develop the framework. It identifies the architecture, processes and scope of practices that evidence suggests is required to support information continuity in a population based approach to care coordination. The framework offers value to policy makers and practitioners as a map that identifies the multi-level elements of an integrated system capable of driving better coordination. Testing of the framework in different settings could aid our understanding of information continuity as a mechanism for linking coordination strategies that operate at different levels of the health system and enable synthesis of findings for informing policy and practice.

Out-of-pocket expenditure by Australian seniors with chronic disease: the effect of specific diseases and morbidity clusters.

BACKGROUND: Out of pocket expenditure (OOPE) on healthcare is related to the burden of illness and the number of chronic conditions a patient experiences, but the relationship of these costs to particular conditions and groups of conditions is less studied. This study examines the effect on OOPE of various morbidity groupings, and explores the factors associated with a 'heavy financial burden of OOPE' defined by an expenditure of over 10% of equivalised household income on healthcare. METHODS: Data were collected from 4,574 senior Australians using a stratified sampling procedure by age, rurality and state of residence. Natural clusters of chronic conditions were identified using cluster analysis and clinically relevant clusters based on expert opinion. We undertook logistic regression to model the probability of incurring OOPE, and a heavy financial burden; linear regression to explore the significant factors of OOPE; and two-part models to estimate the marginal effect of factors on OOPE. RESULTS: The mean OOPE in the previous three months was AU$353; and 14% of respondents experienced a heavy financial burden. Medication and medical service expenses were the major costs. Those who experienced cancer, high blood pressure, diabetes or depression were likely to report higher OOPE. Patients with cancer or diabetes were more likely than others to face a heavy burden of OOPE relative to income. Total number of conditions and some specific conditions predict OOPE but neither the clusters nor pairs of conditions were good predictors of OOPE. CONCLUSIONS: Total number of conditions and some specific conditions predict both OOPE and heavy financial burden but particular comorbid groupings are not useful in predicting OOPE. Low-income patients pay a higher proportion of income than the well-off as OOPE for healthcare. Interventions targeting those who are likely to face severe financial burdens due to their health could address some of these differences.

Multimorbidity and comorbidity of chronic diseases among the senior Australians: prevalence and patterns.

Understanding patterns and identifying common clusters of chronic diseases may help policymakers, researchers, and clinicians to understand the needs of the care process better and potentially save both provider and patient time and cost. However, only limited research has been conducted in this area, and ambiguity remains as those limited previous studies used different approaches to identify common clusters and findings may vary with approaches. This study estimates the prevalence of common chronic diseases and examines co-occurrence of diseases using four approaches: (i) identification of the most occurring pairs and triplets of comorbid diseases; performing (ii) cluster analysis of diseases, (iii) principal component analysis, and (iv) latent class analysis. Data were collected using a questionnaire mailed to a cross-sectional sample of senior Australians, with 4574 responses. Eighty-two percent of respondents reported having at least one chronic disease and over 52% reported having at least two chronic diseases. Respondents suffering from any chronic diseases had an average of 2.4 comorbid diseases. Three defined groups of chronic diseases were identified: (i) asthma, bronchitis, arthritis, osteoporosis and depression; (ii) high blood pressure and diabetes; and (iii) cancer, with heart disease and stroke either making a separate group or "attaching" themselves to different groups in different analyses. The groups were largely consistent across the approaches. Stability and sensitivity analyses also supported the consistency of the groups. The consistency of the findings suggests there is co-occurrence of diseases beyond chance, and patterns of co-occurrence are important for clinicians, patients, policymakers and researchers. Further studies are needed to provide a strong evidence base to identify comorbid groups which would benefit from appropriate guidelines for the care and management of patients with particular disease clusters.

Time spent by people managing chronic obstructive pulmonary disease indicates biographical disruption.

Since Bury's 1982 proposal that chronic illness creates biographical disruption for those who are living with it, there has been no effort to quantitatively measure such disruption. "Biographical disruption" refers to the substantial and directive influence that chronic illness can have over the course of a person's life. Qualitative research and time use studies have demonstrated that people with chronic illnesses spend considerable amounts of time managing their health, and that these demands may change over time. This study was designed to measure the time that older people with chronic illnesses spend on selected health practices as one indicator of biographical disruption. We look specifically at the time use of people with chronic obstructive pulmonary disease (COPD). As part of a larger time use survey, a recall questionnaire was mailed to 3,100 members of Lung Foundation Australia in 2011. A total of 681 responses were received (22.0% response rate), 611 of which were from people with COPD. Descriptive analyses were undertaken on the amount of time spent on selected health-related activities including personal care, nonclinical health-related care, and activity relating to health services. Almost all people with COPD report spending some time each day on personal or home-based health-related tasks, with a median time of 15 minutes per day spent on these activities. At the median, people also report spending about 30 minutes per day exercising, 2.2 hours per month (the equivalent of 4.4 minutes per day) on nonclinical health-related activities, and 4.1 hours per month (equivalent to 8.2 minutes per day) on clinical activities. Excluding exercise, the median total time spent on health-related activities was 17.8 hours per month (or 35.6 minutes per day). For people in the top 10% of time use, the total amount of time was more than 64.6 hours per month (or 2.2 hours per day) excluding exercise, and 104 hours per month (or 3.5 hours per day) including exercise. The amount of time spent on health-related activity, such as engaging in personal care tasks, may be regular and predictable. The execution of these tasks generally takes relatively small amounts of time, and might be incorporated into daily life (biography) without causing significant disruption. Other activities may require large blocks of time, and they may be disruptive in a practical way that almost inevitably disrupts biography. The amount of time required does not appear to alter in relation to the time since diagnosis. The scale of time needed to manage one's health could easily be interpreted as disruptive, and for some people, even overwhelming.

What motivates Australian health service users with chronic illness to engage in self-management behaviour?

CONTEXT: Health policy in Australia emphasizes the role of health service users (HSU) in managing their own care but does not include mechanisms to assist HSUs to do so. OBJECTIVE: To describe motivation towards or away from self-management in a diverse group of older Australians with diabetes, chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD) and suggest policy interventions to increase patient motivation to manage effectively. DESIGN: Content and thematic analyses of in-depth semi-structured interviews. Participants were asked to describe their experience of having chronic illness, including experiences with health professionals and health services. Secondary analysis was undertaken to expose descriptions of self-management behaviours and their corresponding motivational factors. PARTICIPANTS: Health service users with diabetes, COPD and/or CHF (N=52). RESULTS: Participant descriptions exposed internal and external sources of motivation. Internal motivation was most often framed positively in terms of the desire to optimize health, independence and wellness and negatively in terms of avoiding the loss of those attributes. External motivation commonly arose from interactions with family, carers and health professionals. Different motivators appeared to work simultaneously and interactively in individuals, and some motivators seemed to be both positive and negative drivers. CONCLUSION: Successful management of chronic illness requires recognition that the driving forces behind motivation are interconnected. In particular, the significance of family as an external source of motivation suggests a need for increased investment in the knowledge and skill building of family members who contribute to care.

Preferences, predictions and patient enablement: a preliminary study.

BACKGROUND: The widely used patient enablement instrument (PEI) is sometimes contrasted against measures of patient satisfaction as being a more objective measure of consultation quality, in that it is less likely to be positively influenced by fulfilling pre-existing expectations for specific consultation outcomes (such as prescriptions or referrals). However the relationship between expectation and enablement is underexplored, as is the relationship between 'expectation' understood as a patient preference for outcome, and patient prediction of outcome. The aims of the study are to 1) assess the feasibility of measuring the relationship between expectation fulfilment and patient enablement, and 2) measure the difference (if any) between expectation understood as preference, and expectation understood as prediction. METHODS: A questionnaire study was carried out on 67 patients attending three General Practices in the Australian Capital Territory. Patient preferences and predictions for a range of possible outcomes were recorded prior to the consultation. PEI and the actual outcomes of the consultation were recorded at the conclusion of the consultation. Data analysis compared expectation fulfilment as concordance between the preferred, predicted, and actual outcomes, with the PEI as a dependant variable. RESULTS: No statistically significant relationship was found between either preference-outcome concordance and PEI, or prediction-outcome concordance. Statistically insignificant trends in both cases ran counter to expectations; i.e. with PEI (weakly) positively correlated with greater discordance. The degree of concordance between preferred outcomes and predicted outcomes was less than the concordance between either preferred outcomes and actual outcomes, or predicted outcomes and actual outcomes. CONCLUSIONS: The relationship between expectation fulfilment and enablement remains uncertain, whether expectation is measured as stated preferences for specific outcomes, or the predictions made regarding receiving such outcomes. However the lack of agreement between these two senses of 'patient expectation' suggests that explicitly demarcating these concepts during study design is strongly advisable.

Time spent on health related activity by older Australians with diabetes.

AIMS: There is little information available about what people do to look after their health, or how long people spend on health activities. This study identifies key health related activities and time taken as part of self management by people with diabetes. Management planning often lacks information that this study provides that would help clinicians and patients to create manageable and do-able plans that patients can follow. METHODS: Data were collected in 2010 using a national survey of people aged 50 years the National Diabetes Services Scheme. Respondents provided recall data on time used for personal health care, non-clinical health activity; and health service interactions. Data were analysed using Stata 12 and SPSS 19. RESULTS: While most people with diabetes spend on average less than 30 minutes a day on health-related activities (excluding exercise), the highest decile of respondents averaged over 100 minutes. Time spent increased with the number of co-existent conditions. Taking medication and sitting in waiting rooms were the most frequently reported activities. The greatest amount of time was spent on daily personal health care activities. CONCLUSION: The time demands of diabetes for older people can be substantial. Better patient engagement in self management might result from a better match in care planning between the illness demands and the patient time availability, with potential to reduce admissions for hospital care.

Time to care? Health of informal older carers and time spent on health related activities: an Australian survey.

BACKGROUND: Little is known about the time spent on specific health related activities by older adult informal carers who assist people with chronic illness. Research has not yet addressed the association between carer health status and their care demands. Such information could inform policy and health system efforts to manage chronic illness. METHODS: We conducted an Australia wide survey using recall questionnaires to record time use. The study asked how much time is spent on "most days" for the most common activities like taking medication, self-treatment and testing, and how much time in the last month on less common activities like attending a physician or shopping associated with health needs. The survey was mailed to 5,000 members of National Seniors Australia; 2,500 registrants on the National Diabetes Services Scheme; and 3,100 members of the Australian Lung Foundation. A total of 2519 people responded, including 313 people who identified as informal carers. Statistical analysis was undertaken using Stata 11. Standard errors and confidence intervals were derived using bootstrapping techniques within Stata 11. RESULTS: Most carers (96.2%) had chronic illness themselves, and those with greater numbers of chronic illnesses were those who faced the greatest overall time demands. The top decile of carers devoted between 8.5 and 10 hours a day to personal and caring health related activities. Informal carers with chronic illness spent more time managing their own health than people with chronic illness who were not informal carers. These carers spent more time on caring for others than on caring for their own health. High levels of caring responsibility were associated with poorer reported carer health. CONCLUSIONS: Policy and health care services will need to adapt to recognise and reduce the time burden on carers who themselves have chronic illness. More carefully targeted investment in the social infrastructure of formal care would free up carers for other activities (including their own care) and holds the potential to improve the quality of life as well as the health outcomes of this population.

Time's up. descriptive epidemiology of multi-morbidity and time spent on health related activity by older Australians: a time use survey.

Most Western health systems remain single illness orientated despite the growing prevalence of multi-morbidity. Identifying how much time people with multiple chronic conditions spend managing their health will help policy makers and health service providers make decisions about areas of patient need for support. This article presents findings from an Australian study concerning the time spent on health related activity by older adults (aged 50 years and over), most of whom had multiple chronic conditions. A recall questionnaire was developed, piloted, and adjusted. Sampling was undertaken through three bodies; the Lung Foundation Australia (COPD sub-sample), National Diabetes Services Scheme (Diabetes sub-sample) and National Seniors Australia (Seniors sub-sample). Questionnaires were mailed out during 2011 to 10,600 older adults living in Australia. 2540 survey responses were received and analysed. Descriptive analyses were completed to obtain median values for the hours spent on each activity per month. The mean number of chronic conditions was 3.7 in the COPD sub-sample, 3.4 in the Diabetes sub-sample and 2.0 in the NSA sub-sample. The study identified a clear trend of increased time use associated with increased number of chronic conditions. Median monthly time use was 5-16 hours per month overall for our three sub-samples. For respondents in the top decile with five or more chronic conditions the median time use was equivalent to two to three hours per day, and if exercise is included in the calculations, respondents spent from between five and eight hours per day: an amount similar to full-time work. Multi-morbidity imposes considerable time burdens on patients. Ageing is associated with increasing rates of multi-morbidity. Many older adults are facing high demands on their time to manage their health in the face of decreasing energy and mobility. Their time use must be considered in health service delivery and health system reform.

Consultations with complementary and alternative medicine practitioners by older Australians: results from a national survey.

BACKGROUND: The use of complementary and alternative medicines (CAM) and CAM practitioners is common, most frequently for the management of musculoskeletal conditions. Knowledge is limited about the use of CAM practitioners by older people, and specifically those with other long term or chronic conditions. METHODS: In 2011 we conducted an Australia wide survey targeting older adults aged over 50 years (n = 2540). Participants were asked to identify their chronic conditions, and from which health professionals they had 'received advice or treatment from in the last 3 months', including 'complementary health practitioners, e.g. naturopath'. Descriptive analyses were undertaken using SPSS and STATA software. RESULTS: Overall, 8.8% of respondents reported seeing a CAM practitioner in the past three months, 12.1% of women and 3.9% of men; the vast majority also consulting medical practitioners in the same period. Respondents were more likely to report consulting a CAM practitioner if they had musculoskeletal conditions (osteoporosis, arthritis), pain, or depression/anxiety. Respondents with diabetes, hypertension and asthma were least likely to report consulting a CAM practitioner. Those over 80 reported lower use of CAM practitioners than younger respondents. CAM practitioner use in a general older population was not associated with the number of chronic conditions reported, or with the socio-economic level of residence of the respondent. CONCLUSION: Substantial numbers of older Australians with chronic conditions seek advice from CAM practitioners, particularly those with pain related conditions, but less often with conditions where there are clear treatment guidelines using conventional medicine, such as with diabetes, hypertension and asthma. Given the policy emphasis on better coordination of care for people with chronic conditions, these findings point to the importance of communication and integration of health services and suggest that the concept of the 'treating team' needs a broad interpretation.

Health work by older people with chronic illness: how much time does it take?

PURPOSE: People living with chronic illness report spending a lot of time managing their health, attempting to balance the demands of their illness/es with other activities. This study was designed to measure the time older people with chronic illness spend on specific health-related activities. Key methods: Data were collected in 2010 using a national survey of people aged 50 years and over selected from the membership of National Seniors Australia, the Diabetes Services Scheme and The Lung Foundation. Respondents provided recall data on time used for personal health care, non-clinical health activity; and health service interactions. MAIN RESULTS: While most people with a chronic illness spend on average less than 30 minutes a day on health-related activities, the highest decile of respondents averaged at least 2 hours each day. People with COPD report the highest expenditure of time. The greatest amount of time was spent on daily personal health care activities. MAIN CONCLUSION: For a minority of people with chronic illness, time demands for health-related activities can be so great that other activities must be affected. Some time demands are amenable to system interventions that would result in a more patient-centered organisation of care.