Use of frailty assessment instruments in nephrology populations: a scoping review.

BACKGROUND: Frailty is a clinical syndrome of accelerated aging associated with adverse outcomes. Frailty is prevalent among patients with chronic kidney disease but is infrequently assessed in clinical settings, due to lack of consensus regarding frailty definitions and diagnostic tools. This study aimed to review the practice of frailty assessment in nephrology populations and evaluate the context and timing of frailty assessment. METHODS: The search included published reports of frailty assessment in patients with chronic kidney disease, undergoing dialysis or in receipt of a kidney transplant, published between January 2000 and November 2021. Medline, CINAHL, Embase, PsychINFO, PubMed and Cochrane Library databases were examined. A total of 164 articles were included for review. RESULTS: We found that studies were most frequently set within developed nations. Overall, 161 studies were frailty assessments conducted as part of an observational study design, and 3 within an interventional study. Studies favoured assessment of participants with chronic kidney disease (CKD) and transplant candidates. A total of 40 different frailty metrics were used. The most frequently utilised tool was the Fried frailty phenotype. Frailty prevalence varied across populations and research settings from 2.8% among participants with CKD to 82% among patients undergoing haemodialysis. Studies of frailty in conservatively managed populations were infrequent (N = 4). We verified that frailty predicts higher rates of adverse patient outcomes. There is sufficient literature to justify future meta-analyses. CONCLUSIONS: There is increasing recognition of frailty in nephrology populations and the value of assessment in informing prognostication and decision-making during transitions in care. The Fried frailty phenotype is the most frequently utilised assessment, reflecting the feasibility of incorporating objective measures of frailty and vulnerability into nephrology clinical assessment. Further research examining frailty in low and middle income countries as well as first nations people is required. Future work should focus on interventional strategies exploring frailty rehabilitation.

The 'safe death': An ethnographic study exploring the perspectives of rural palliative care patients and family caregivers.

BACKGROUND: In rural settings, relationships between place and self are often stronger than for urban residents, so one may expect that rural people would view dying at home as a major feature of the 'good death'. AIM: To explore the concept of the 'good death' articulated by rural patients with life-limiting illnesses, and their family caregivers. DESIGN: Ethnography, utilising open-ended interviews, observations and field-notes. PARTICIPANTS: In total, 12 rural (town and farm) patients with life-limiting illnesses, 18 family caregivers and 6 clinicians, in the Snowy Monaro region of New South Wales, Australia, participated in this study over the course of the deaths of the patients. Interviews were transcribed and analysed with observational data using an emergent thematic process. RESULTS: A 'safe death' was central to a 'good death' and was described as a death in which one could maintain (1) a connection with one's previous identity; (2) autonomy and control over decisions regarding management of end-of-life care and (3) not being overwhelmed by the physical management of the dying process. For all participants, the preferred place of death was the 'safe place', regardless of its physical location. CONCLUSION: Safety, in this study, is related to a familiar place for death. A home death is not essential for and does not ensure a 'good death'. We all have a responsibility to ensure all places for dying can deliver the 'safe death'. Future research could explore the inter-relationships between safety and preference for home or home-like places of death.

Place of death in the Snowy Monaro region of New South Wales: A study of residents who died of a condition amenable to palliative care.

OBJECTIVE: To describe the place of death of residents in a rural region of New South Wales. DESIGN: Cross-sectional quantitative study using death data collected from local funeral directors (in person and websites), residential aged-care facilities, one multipurpose heath service and obituary notices in the local media (newspapers/radio). SETTING: Snowy Monaro region (New South Wales Australia). PARTICIPANTS: Residents, with advanced frailty or one of 10 conditions amenable to palliative care, who died between 1 February 2015 and 31 May 2016. MAIN OUTCOME MEASURE: Place of death. RESULTS: Of 224 deaths in this period, 138 were considered amenable to palliative care. Twelve per cent of these deaths occurred in a private residence, 38% in the usual place of residence and 91% within the region. CONCLUSION: Most rural residents with conditions amenable to palliative care died in the region. Most did not die in their usual place of residence. Further qualitative work is needed to determine palliative care patients' and family caregivers' preferences for, and the importance placed on, place of death. While there may be a need to support an increase in home deaths, local rural hospitals and residential aged-care facilities must not be overlooked as a substitute for inpatient hospices.

Rural end-of-life care from the experiences and perspectives of patients and family caregivers: A systematic literature review.

BACKGROUND: End-of-life care must be relevant to the dying person and their family caregiver regardless of where they live. Rural areas are distinct and need special consideration. Gaining end-of-life care experiences and perspectives of rural patients and their family caregivers is needed to ensure optimal rural care. AIMS: To describe end-of-life care experiences and perspectives of rural patients and their family caregivers, to identify facilitators and barriers to receiving end-of-life care in rural/remote settings and to describe the influence of rural place and culture on end-of-life care experiences. DESIGN: A systematic literature review utilising the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: Four databases (PubMed, CINAHL, Scopus and Web of Science) were searched in January 2016, using a date filter of January 2006 through January 2016; handsearching of included article references and six relevant journals; one author contacted; pre-defined search terms and inclusion criteria; and quality assessment by at least two authors. RESULTS: A total of 27 articles (22 rural/remote studies) from developed and developing countries were included, reporting rural end-of-life care experiences and perspectives of patients and family caregivers. Greatest needs were informational (developed countries) and medications (developing countries). Influence of rural location included distances, inaccessibility to end-of-life care services, strong community support and importance of home and 'country'. CONCLUSION: Articulation of the rural voice is increasing; however, there still remain limited published rural studies reporting on patient and family caregivers' experiences and perspectives on rural end-of-life care. Further research is encouraged, especially through national and international collaborative work.

Place of death in rural palliative care: A systematic review.

BACKGROUND: There have been many studies on the actual and preferred place of care and death of palliative patients; however, most have been whole population surveys and/or urban focused. Data and preferences for terminally ill rural patients and their unofficial carers have not been systematically described. AIM: To describe the actual place of death and preferred place of care and/or death in rural palliative care settings. METHOD: A systematic mixed studies review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. DATA SOURCE: PubMed, PsychINFO, Scopus and CINAHL databases were searched (September to December 2014); eligible quantitative and qualitative studies included preferred and/or actual place of death/care of rural, regional or remote residents; rural data that are clearly identifiable; death due to palliative condition (malignant and non-malignant) or survey of participants with current or hypothetical life-limiting illness. RESULTS: A total of 25 studies described actual place of death; 12 preferred place of care or death (2 studies reported both); most deaths occurred in hospital with home as the preferred place of care/death; however qualitative studies suggest that preferences are not absolute; factors associated with place are not adequately described as rurality was an independent variable; significant heterogeneity (rural setting and participants), however, many areas had a greater chance of home death than in cities; rural data are embedded in population reports rather than from specific rural studies. CONCLUSION: Home is the preferred place of rural death; however, more work is needed to explore influencing factors, absolute importance of preferences and experience of providing and receiving palliative care in rural hospitals which often function as substitute hospice.

Perspectives on the working hours of Australian junior doctors.

The working hours of junior doctors have been a focus of discussion in Australia since the mid-1990s. Several national organizations, including the Australian Medical Association (AMA), have been prominent in advancing this agenda and have collected data (most of which is self-reported) on the working hours of junior doctors over the last 15 years. Overall, the available data indicate that working hours have fallen in a step-wise fashion, and AMA data suggest that the proportion of doctors at high risk of fatigue may be declining. It is likely that these changes reflect significant growth in the number of medical graduates, more detailed specifications regarding working hours in industrial agreements, and a greater focus on achieving a healthy work-life balance. It is notable that reductions in junior doctors' working hours have occurred despite the absence of a national regulatory framework for working hours. Informed by a growing international literature on working hours and their relation to patient and practitioner safety, accreditation bodies such as the Australian Commission on Safety and Quality in Health Care (ACSQHC) and the Australian Medical Council (AMC) are adjusting their standards to encourage improved work and training practices.

Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD.

Frailty is a multidimensional clinical syndrome characterized by low physical activity, reduced strength, accumulation of multiorgan deficits, decreased physiological reserve, and vulnerability to stressors. Frailty has key social, psychological, and cognitive implications. Frailty is accelerated by uremia, leading to a high prevalence of frailty in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as well as contributing to adverse outcomes in this patient population. Frailty assessment is not routine in patients with CKD; however, a number of validated clinical assessment tools can assist in prognostication. Frailty assessment in nephrology populations supports shared decision-making and advanced communication and should inform key medical transitions. Frailty screening and interventions in CKD or ESKD are a developing research priority with a rapidly expanding literature base.

Feasibility and acceptability of using bronchial hyperresponsiveness to manage asthma in primary care: a pilot study.

AIMS: To determine if indirect testing for bronchial hyperresponsiveness (BHR) to monitor inhaled corticosteroid (ICS) treatment in asthma is feasible and acceptable in primary care. METHODS: Fourteen adult patients with asthma aged 22-70 years (4M:10F, forced expiratory volume in 1 s >70% predicted) taking ICS performed a test for BHR using mannitol on three visits 6 weeks apart. ICS dose adjustments were made based on the presence of BHR. The Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire were used at each visit. A semi structured interview at study exit assessed subject acceptability. RESULTS: BHR did not return in those with no BHR at study entry (n=9) with decreasing ICS dose. Improvements in BHR with increasing ICS dose (n=5) were observed with clinically significant improvements in AQLQ (mean score increase >0.5, p=0.02). Feasibility and acceptability of BHR testing was demonstrated. CONCLUSIONS: It is feasible and acceptable to perform BHR testing using mannitol to help identify patients with asthma who would benefit from ICS dose increases and those with no BHR who could have a dose reduction. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ACTRN12610000807055.

Chronic disease management items in general practice: a population-based study of variation in claims by claimant characteristics.

OBJECTIVE: To describe how Medical Benefits Schedule (MBS) chronic disease (CD) item claims vary by sociodemographic and health characteristics in people with heart disease, asthma or diabetes. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional analysis of linked unit-level MBS and survey data from the first 102,934 participants enrolled in the 45 and Up Study, a large-scale cohort study in New South Wales, who completed the baseline survey between January 2006 and July 2008. MAIN OUTCOME MEASURE: Claim for any general practitioner CD item within 18 months before enrolment, ascertained from MBS records. RESULTS: The proportion of individuals making claims for MBS CD items was 18.5% for asthma, 22.3% for heart disease, and 44.9% for diabetes. Associations between participant characteristics and a claim for a CD item showed similar patterns across the three diseases. For heart disease and asthma, people most likely to claim a CD item were women, older, of low income and education levels, with multiple chronic conditions, fair or poor self-rated health, obesity and low physical activity levels. The pattern of claims was slightly different for participants with diabetes in that there was no significant association with number of chronic conditions, smoking or physical activity. CONCLUSIONS: Many individuals with self-reported CD do not claim CD items. People with diabetes and individuals with greatest need based on health, socioeconomic and lifestyle risk factors are the most likely to claim CD items.

Views of GPs and practice nurses on support needed to respond to pandemic influenza: a qualitative study.

INTRODUCTION: Five years ago Australia, and the world, placed itself on heightened alert for pandemic influenza, based on concerns about the potential spread of the avian influenza virus. This prompted a flurry of preparation activity involving general practice, with information from various sources; government, colleges and divisions of general practice. METHOD: To assess how general practitioners and practice nurses perceive this information, practice nurses and general practitioners were interviewed as part of a larger project exploring the role of the Australian general practice sector in an influenza pandemic. Results were validated by two focus groups and scenario sessions. FINDINGS: Participants perceived that non-government organisations rarely gave useful information during a pandemic outbreak. Local divisions were perceived as having a practical and useful role, providing hands-on support to practices during a pandemic outbreak. Our participants did not perceive any coordination in the delivery of information sent by all the organisations involved in a pandemic response and therefore rejected our second hypothesis. CONCLUSIONS: More planning needs to go into the coordinated response of the general practice sector to a pandemic, and such a response should include the support of local Divisions, both as a conduit for information and to assist practices to develop response plans.

Policy options to improve leadership of middle managers in the Australian residential aged care setting: a narrative synthesis.

BACKGROUND: The prevalence of both chronic diseases and multi-morbidity increases with longer life spans. As Australia's population ages, the aged care sector is under increasing pressure to ensure that quality aged care is available. Key to responding to this pressure is leadership and management capability within the aged care workforce. A systematic literature review was conducted to inform the policy development necessary for the enhancement of clinical and managerial leadership skills of middle managers within residential aged care. METHODS: Using scientific journal databases, hand searching of specialist journals, Google, snowballing and suggestions from experts, 4,484 papers were found. After a seven-tiered culling process, we conducted a detailed review (narrative synthesis) of 153 papers relevant to leadership and management development in aged care, incorporating expert and key stakeholder consultations. RESULTS: * Positive staff experiences of a manager's leadership are critical to ensure job satisfaction and workforce retention, the provision of quality care and the well-being of care recipients, and potentially a reduction of associated costs.* The essential attributes of good leadership for aged care middle management are a hands-on accessibility and professional expertise in nurturing respect, recognition and team building, along with effective communication and flexibility. However, successful leadership and management outcomes depend on coherent and good organisational leadership (structural and psychological empowerment).* There is inadequate preparation for middle management leadership roles in the aged care sector and a lack of clear guidelines and key performance indicators to assess leadership and management skills.* Theory development in aged care leadership and management research is limited. A few effective generic clinical leadership programs targeting both clinical and managerial leaders exist. However, little is known regarding how appropriate and effective they are for the aged care sector. CONCLUSIONS: There is an urgent need for a national strategy that promotes a common approach to aged care leadership and management development, one that is sector-appropriate and congruent with the philosophy of person-centred care now predominant in the sector. The onus is on aged care industries as a whole and various levels of Government to make a concerted effort to establish relevant regulation, legislation and funding.

The experience of living with chronic heart failure: a narrative review of qualitative studies.

BACKGROUND: Chronic heart failure (CHF) is the leading cause of all hospitalisations and readmissions in older people, accounting for a large proportion of developed countries' national health care expenditure. CHF can severely affect people's quality of life by reducing their independence and ability to undertake certain activities of daily living, as well as affecting their psychosocial and economic capacity. This paper reports the findings of a systematic narrative review of qualitative studies concerning people's experience of living with CHF, aiming to develop a wide-ranging understanding of what is known about the patient experience. METHODS: We searched eight relevant electronic databases using the terms based on the diagnosis of 'chronic heart failure', 'heart failure' and 'congestive heart failure' and qualitative methods, with restrictions to the years 1990-May 2008. We also used snowballing, hand searching and the expert knowledge of the research team to ensure all relevant papers were included in the review. Of 65 papers collected less than half (n = 30) were found relevant for this review. These papers were subsequently summarised and entered into QSR NVivo7 for data management and analysis. RESULTS: The review has identified the most prominent impacts of CHF on a person's everyday life including social isolation, living in fear and losing a sense of control. It has also identified common strategies through which patients with CHF manage their illness such as sharing experiences and burdens with others and being flexible to changing circumstances. Finally, there are multiple factors that commonly impact on patients' self care and self-management in the disease trajectory including knowledge, understanding and health service encounters. These health service encounters encompass access, continuity and quality of care, co-morbid conditions, and personal relationships. CONCLUSIONS: The core and sub-concepts identified within this study provide health professionals, service providers, policy makers and educators with broad insights into common elements of people's experiences of CHF and potential options for improving their health and wellbeing. Future studies should focus on building a comprehensive picture of CHF through examination of differences between genders, and differences within age groups, socioeconomic groups and cultural groups.

A pilot study of the use of oral ivermectin to treat head lice in primary school students in Australia.

Head lice are a common, costly public health problem worldwide. We aimed to determine the feasibility of an ivermectin intervention program. Consenting students in two schools were screened for head lice. Infested students and siblings at one school were offered a head lice fact sheet and two doses of oral ivermectin, 7 days apart. Parents of infested students in the other school were given the same fact sheet and asked to treat the child and siblings using their preferred topical treatment. Seven hundred two of 754 (93.1%) students enrolled in the two schools were screened; 40 (5.3%; 95% CI 3.7-6.9) had head lice; 31 (9.4%; 95% CI 6.1-12.2) in the intervention school and nine (2.5%; 95% CI 1.1-3.8) in the control school. Subsequently 93.6% of children in the intervention school were treated with oral ivermectin. No adverse events were reported. At 6 months the reduction in the head lice infestation rates for the intervention and control schools were 87% and 56%, respectively. This pilot study suggests that school wide screening for head lice and the administration of oral ivermectin is feasible and acceptable. A randomized controlled trial at 20 schools is planned.

Identifying the policy implications of competency-based education.

At their 2009 consensus conference, the International CBME Collaborators proposed a number of central tenets of CBME in order to advance the field of medical education. Although the proposed conceptualization of CBME offers several advantages and opportunities, including a greater emphasis on outcomes, a mechanism for the promotion of learner-centred curricula, and the potential to move away from time-based training and credentialing in medicine, it is also associated with several significant barriers to adoption. This paper examines the concepts of CBME through a broad educational policy lens, identifying considerations for medical education leaders, health care institutions, and policy-makers at both the meso (program, institutional) and macro (health care system, inter-jurisdictional, and international) levels. Through this analysis, it is clear that CBME is associated with a number of complex challenges and questions, and cannot be considered in isolation from the complex systems in which it functions. Much more work is needed to engage stakeholders in dialogue, to debate the issues, and to identify possible solutions.

Competency-based medical education: theory to practice.

Although competency-based medical education (CBME) has attracted renewed interest in recent years among educators and policy-makers in the health care professions, there is little agreement on many aspects of this paradigm. We convened a unique partnership - the International CBME Collaborators - to examine conceptual issues and current debates in CBME. We engaged in a multi-stage group process and held a consensus conference with the aim of reviewing the scholarly literature of competency-based medical education, identifying controversies in need of clarification, proposing definitions and concepts that could be useful to educators across many jurisdictions, and exploring future directions for this approach to preparing health professionals. In this paper, we describe the evolution of CBME from the outcomes movement in the 20th century to a renewed approach that, focused on accountability and curricular outcomes and organized around competencies, promotes greater learner-centredness and de-emphasizes time-based curricular design. In this paradigm, competence and related terms are redefined to emphasize their multi-dimensional, dynamic, developmental, and contextual nature. CBME therefore has significant implications for the planning of medical curricula and will have an important impact in reshaping the enterprise of medical education. We elaborate on this emerging CBME approach and its related concepts, and invite medical educators everywhere to enter into further dialogue about the promise and the potential perils of competency-based medical curricula for the 21st century.

Achieving a balanced life in the face of chronic illness.

The increasing prevalence of chronic disease is a driver of health system reform in most economically advanced nations. A consistent theme within these reforms is building greater patient-centredness into the health care delivery. This study aims to develop an in-depth understanding of the experience of patients and family carers affected by chronic illness that will be the basis on which to propose policy and health system interventions that are patient-centred. Participants struggled with the ongoing tasks of balancing their lives with the increasing demands and intrusion of chronic illness. Their attempts to achieve a balance were seriously hampered by fragmented services, complexity in navigating health services, relationships with health professionals and others, and co-morbidity. Future policy directions include designing models of care and infrastructure that enable patients and their family carers to balance life and illness, and aligning patient-centred care not only within health services but also with community and social support services.

Challenges for co-morbid chronic illness care and policy in Australia: a qualitative study.

BACKGROUND: In response to the escalating burden of chronic illness in Australia, recent health policies have emphasised the promotion of patient self-management and better preventive care. A notable omission from these policies is the acknowledgment that patients with chronic illness tend to have co-morbid conditions. Our objectives were: to identify the common challenges co-morbidity poses to patients and carers in their experiences of self-management; to detail the views and perceptions of health professionals about these challenges; and to discuss policy options to improve health care for people with co-morbid chronic illness. The method included semi-structured interviews and focus groups with 129 purposively sampled participants. Participants were people with Type 2 diabetes, chronic obstructive pulmonary disease and/or chronic heart failure as well as carers and health care professionals. Content analysis of the interview data was conducted using NVivo7 software. RESULTS: Patients and their carers found co-morbidity influenced their capacity to manage chronic illness in three ways. First, co-morbidity created barriers to patients acting on risk factors; second, it complicated the process of recognising the early symptoms of deterioration of each condition, and third, it complicated their capacity to manage medication. CONCLUSION: Findings highlight challenges that patients with multiple chronic conditions face in relation to preventive care and self-management. Future clinical policy initiatives need to move away from single illness orientation toward strategies that meet the needs of people with co-morbid conditions and strengthen their capacity to self-manage. These patients will benefit directly from specialised education and services that cater to the needs of people with clusters of co-morbidities.

Health-related lifestyles and obesity among adults with and without disability in Australia: Implication for mental health care.

BACKGROUND: Numerous studies have reported people with disabilities are more likely to be obese and engaged in unhealthy lifestyles. Few studies explored the mechanism of health-related lifestyles and obesity among people with disabilities. OBJECTIVE: We aimed to investigate health-related lifestyles and obesity in relation to disability among Australian adults. We further aimed to explore the potential mediating effect of psychological distress for disability in relation to health related lifestyles and obesity. METHODS: Using the National Health Survey conducted in 2015 in Australia, we considered non-institutionalised adult participants (aged 18 + years old) as our study population (n = 11,598). Study outcomes included currently smoking, smoking daily, alcohol consumption, physical exercises, and obesity. We considered high psychological distress (Kessler 10 scores ≥ 22) a potential mediator for the disability-lifestyles and disability-obesity associations. Sample weights were calculated allowing for complex survey design. Adjusted Odds Ratios and 95% Confidence Intervals were evaluated using weighted Logistic regression models. RESULTS: Compared to their disability-free counterparts, people with disabilities were more likely to be current smokers (aOR: 1.26, 95%CI: 1.08-1.47) and have obesity problems (1.44, 1.27-1.64), and were less likely to do physical exercises (0.67, 0.58-0.77), after controlling for socio-environmental factors. In the presence of high psychological distress, the disability-smoking association was no longer significant, and associations of disability-exercise (0.72, 0.62-0.84) and disability-obesity (1.38, 1.22-1.57) were influenced but remained significant. CONCLUSION: High psychological distress demonstrated important mediating effects. Tailored mental health care for people with disabilities might have the utility to reduce unhealthy behaviors.