Trends and projections of cause-specific premature mortality in Australia to 2044: a statistical modelling study.

Background: Long-term projections of premature mortality (defined as deaths age <75 years) help to inform decisions about public health priorities. This study aimed to project premature mortality rates in Australia to 2044, and to estimate numbers of deaths and potential years of life lost (PYLL) due to premature mortality overall and for 59 causes. Methods: We examined the past trends in premature mortality rates using Australian mortality data by sex, 5-year age group and 5-year calendar period up to 2019. Cigarette smoking exposure data (1945-2019) were included to project lung cancer mortality. Age-period-cohort or generalised linear models were developed and validated for each cause to project premature mortality rates to 2044. Findings: Over the 25-year period from 1990-1994 to 2015-2019, there was a 44.4% decrease in the overall age-standardised premature mortality rate. This decline is expected to continue, from 162.4 deaths/100,000 population in 2015-2019 to 141.7/100,000 in 2040-2044 (12.7% decrease). Despite declining rates, total numbers of premature deaths are projected to increase by 22.8%, rising from 272,815 deaths in 2015-2019 to 334,894 deaths in 2040-2044. This is expected to result in 1.58 million premature deaths over the 25-year period 2020-2044, accounting for 24.5 million PYLL. Of the high-level cause categories, cancer is projected to remain the most common cause of premature death in Australia by 2044, followed by cardiovascular disease, external causes (including injury, poisoning, and suicide), and respiratory diseases. Interpretation: Despite continuously declining overall premature mortality rates, the total number of premature deaths in Australia is projected to remain substantial, and cancer will continue to be the leading cause. These projections can inform the targeting of public health efforts and can serve as benchmarks against which to measure the impact of future interventions. They emphasise the ongoing importance of accelerating the prevention, early detection, and treatment of key health conditions. Funding: No funding was provided for this study.

Association of urinary sex hormones with mood and behavior changes in a community adolescent cohort.

OBJECTIVE: To examine the contribution of variation in sex hormone excretion to mood and behavioral changes in adolescent females and males. DESIGN: Prospective, longitudinal observational cohort study. METHODS: Participants were 342 volunteers aged 10-12 years living in rural Australia. Urinary estradiol and testosterone levels measured by liquid chromatography-mass spectrometry were obtained at three-month intervals for three years. Integrated measures (area-under-curve) of urinary steroid excretion summarised as absolute and variability during each 12-month period of the study. Psychosocial data were gathered annually with the primary outcome of depressive symptomatology. Secondary outcomes were the other subscales of the Youth Self-Report, impulsive-aggression, sleep habits, and self-harm. RESULTS: 277 (158 male) participants contributed data over the full duration of the study and could be included in the analyses. In females, analyses of absolute urine hormone levels found no relationship between estradiol and any outcome, but higher testosterone was significantly associated with depression and poorer sleep. Greater variability of both urine estradiol and testosterone was associated with lower total psychopathology, anxious/depressed and social problems scores. Greater variability in urine estradiol was associated with lower attention problems and impulsive aggression in females. In males, higher testosterone and estradiol levels were associated with rule-breaking, and poorer sleep, and no associations were found for gonadal hormone variability for males. CONCLUSIONS: Longitudinal measurement of both iso-sexual and contra-sexual gonadal hormones contributes to a more nuanced view of the impact of sex steroids on mood and behavior in adolescents. These findings may enlighten the understanding of the impact of sex steroids during normal male and female puberty with implications for hormone replacement therapies as well as management of common mood and behavioral problems.

Social and Behavioural Correlates of High Physical Activity Levels among Aboriginal Adolescent Participants of the Next Generation: Youth Wellbeing Study.

Physical activity typically decreases during teenage years and has been identified as a health priority by Aboriginal adolescents. We examined associations between physical activity levels and sociodemographic, movement and health variables in the Aboriginal led 'Next Generation: Youth Well-being (NextGen) Study' of Aboriginal people aged 10-24 years from Central Australia, Western Australia and New South Wales. Baseline survey data collected by Aboriginal researchers and Aboriginal youth peer recruiters from 2018 to 2020 examined demographics and health-related behaviours. Logistic regression was used to estimate odds ratios (OR) for engaging in high levels of physical activity in the past week (3-7 days; 0-2 days (ref), or 'don't remember') associated with demographic and behavioural factors. Of 1170 adolescents, 524 (41.9%) had high levels of physical activity; 455 (36.4%) had low levels; 191 (15.3%) did not remember. Factors independently associated with higher odds of physical activity 3-7 days/week were low weekday recreational screen time [55.3% vs. 44.0%, OR 1.79 (1.16-2.76)], having non-smoking friends [50.4% vs. 25.0%, OR 2.27 (1.03-5.00)] and having fewer friends that drink alcohol [48.1% vs. 35.2%, OR 2.08 (1.05-4.14)]. Lower odds of high physical activity were independently associated with being female [40.2% vs. 50.9%, OR 0.57 (0.40-0.80)] and some findings differed by sex. The NextGen study provides evidence to inform the co-design and implementation of strategies to increase Aboriginal adolescent physical activity such as focusing on peer influences and co-occurring behaviours such as screen time.

Lesbian, gay, bisexual, transgender and gender diverse and queer (LGBTQ) community members' perspectives on palliative care in New South Wales (NSW), Australia.

Lesbian, gay, bisexual, transgender and gender diverse people, and queer people (LGBTQ people) are at increased risk of some chronic diseases and cancers. NSW Health palliative care health policy prioritises equitable access to quality care, however, little is known about community members' perspectives on palliative care. This study aimed to understand LGBTQ community views and preferences in palliative care in NSW. A community survey and follow-up interviews with LGBTQ people in NSW were conducted in mid-2020. A total of 419 people responded to the survey, with 222 completing it. Six semi-structured phone interviews were conducted with participants who volunteered for follow-up. The sample included LGBTQ people with varied levels of experience in palliative care. Thematic analysis was conducted on survey and interview data, to identify perceived barriers and enablers, and situate these factors in the socio-ecological model of health. Some perceived barriers from community members related to considering whether to be 'out' (i.e., making one's sexual orientation and gender known to services), knowledge and attitudes of staff, concern about potential substandard care or mistreatment (particularly for transgender health), decision making, biological family as a source of tension, and loneliness and isolation. Perceived enablers related to developing and distributing inclusive palliative care information, engaging with community(ies), fostering inclusive and non-discriminatory service delivery, ensuring respectful approaches to person-centred care, and staff training on and awareness building of LGBTQ needs and issues. Most of the participants who had experienced palliative care recounted positive interactions, however, we identified that LGBTQ people require better access to knowledgeable and supportive services. Palliative care information should be inclusive and services respectful and welcoming. Particular consideration should be given to how services respond to and engage with people from diverse population groups. These insights can support ongoing policy and service development activities to further enhance palliative care.

Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Distal radius fractures are common and are managed with or without surgery. Current evidence indicates surgical treatment is not superior to nonsurgical treatment at 12 months. Objective: Does surgical treatment for displaced distal radius fractures in patients 60 years or older provide better patient-reported wrist pain and function outcomes than nonsurgical treatment at 24 months? Design, Setting, and Participants: In this secondary analysis of a combined multicenter randomized clinical trial (RCT) and a parallel observational study, 300 patients were screened from 19 centers in Australia and New Zealand. Of these, 166 participants were randomized to surgical or nonsurgical treatment. Participants who declined randomization (n = 134) were included in the parallel observational group with the same treatment options and follow-up. Participants were followed up at 3, 12, and 24 months by a blinded assessor. The 24-month outcomes are reported herein. Data were collected from December 1, 2016, to December 31, 2020, and analyzed from February 4 to October 21, 2021. Interventions: Surgical treatment consisting of open reduction and internal fixation using a volar-locking plate (VLP group) and nonsurgical treatment consisting of closed reduction and cast immobilization (CR group). Main Outcomes and Measures: The primary outcome was patient-reported function using the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary outcomes included health-related quality of life, wrist pain, patient-reported treatment success, patient-rated bother with appearance, and posttreatment complications. Results: Among the 166 randomized and 134 observational participants (300 participants; mean [SD] age, 71.2 [7.5] years; 269 women [89.7%]), 151 (91.0%) randomized and 118 (88.1%) observational participants were followed up at 24 months. In the RCT, no clinically important difference occurred in mean PRWE scores at 24 months (13.6 [95% CI, 9.1-18.1] points for VLP fixation vs 15.8 [95% CI, 11.3-20.2] points for CR; mean difference, 2.1 [95% CI, -4.2 to 8.5]; P = .50). There were no between-group differences in all other outcomes except for patient-reported treatment success, which favored VLP fixation (33 of 74 [44.6%] in the CR group vs 54 of 72 [75.0%] in the VLP fixation group reported very successful treatment; P = .002). Rates of posttreatment complications were generally low and similar between treatment groups, including deep infection (1 of 76 [1.3%] in the CR group vs 0 of 75 in the VLP fixation group) and complex regional pain syndrome (2 of 76 [2.6%] in the CR group vs 1 of 75 [1.3%] in the VLP fixation group). The 24-month trial outcomes were consistent with 12-month outcomes and with outcomes from the observational group. Conclusions and Relevance: Consistent with previous reports, these findings suggest that VLP fixation may not be superior to CR for displaced distal radius fractures for patient-rated wrist function in persons 60 years or older during a 2-year period. Significantly higher patient-reported treatment success at 2 years in the VLP group may be attributable to other treatment outcomes not captured in this study. Trial Registration: ANZCTR.org Identifier: ACTRN12616000969460.

The effectiveness of a co-management care model on older hip fracture patients in China - A multicentre non-randomised controlled study.

BACKGROUND: Clinical guidelines recommend orthogeriatric care to improve older hip fracture patients' outcomes, but few studies have been conducted in China. This study evaluated the effects of an orthogeriatric co-management care model in six Chinese hospitals. METHODS: This non-randomised controlled study was designed as an exploratory trial and was conducted in 3 urban and 3 suburban hospitals. Eligible patients were aged ≥ 65 years with X-ray confirmed hip fracture and admitted to hospital within 21 days of injury. All patients received three times follow-ups within one year (1-month, 4-month and 12-month post admission). Co-management care was implemented in 1 urban hospital, while usual care continued in 5 urban and suburban hospitals. Patient demographics, pre-, peri- and post-operative information, complications and mortality were collected at baseline and follow-ups. The primary outcome was proportion of patients receiving surgery within 48 hours from ward arrival. Secondary outcomes included osteoporosis assessment, in-hospital rehabilitation, length of hospital stay, in-hospital mortality and one-year cumulative mortality. FINDINGS: There were 2,071 eligible patients enrolled (1,110 intervention, 961 control). Compared to usual care, a significantly higher proportion of intervention patients received surgery within 48 hours (75% vs 27%, p<0.0001), osteoporosis assessment (99.9% vs 60.6%, p<0.0001), rehabilitation (99.1% vs 3.9%, p<0.0001) and shorter length of hospital stay (6.1 days vs 12.0 days, p<0.0001). The intervention group saw a significant lower in-hospital mortality rate than the control group (adjusted relative risk 0.021, 95% CI 0.001 to 0.45, P=0.01). One-year cumulative mortality was also significantly reduced in the intervention group (hazard ratio 0.59, 95% CI 0.38 to 0.80, p=0.01). INTERPRETATION: Co-management care of older hip fracture patients resulted in better outcomes, including decreased time to surgery, improved clinical management, and reduced one-year mortality. A randomised controlled trial is needed to provide definitive evidence. FUNDING: The study is supported by Capital's Funds for Health Improvement and Research (2018-1-2071).

The role of digital health for post-surgery care of older patients with hip fracture: A scoping review.

BACKGROUND: Digital health interventions can potentially improve the integration of the health care systems. Hip fracture is a serious injury for older people and integrated post-surgery care is vital for good recovery. OBJECTIVE: We aimed to characterise digital health interventions used for hip fracture post-surgery care, and further to examine the extent to which of these interventions address the World Health Organisation (WHO) integrated care for older people (ICOPE) framework. METHODS: A scoping review was conducted, by searching the literature from English and Chinese databases and trial registries. Keywords included hip fracture, post-surgery care and digital health interventions. Interventional, observational, qualitative studies and case reports were included. We used a combined framework, WHO ICOPE and WHO digital health intervention classifications, to support data synthesis. RESULTS: A total of 4,542 articles were identified, of which 39 studies were included in the analysis. We identified only six randomised controlled trials. Digital health interventions were mainly used to help doctors provide clinical care and facilitate service delivery between the patients and healthcare providers. No studies focused on health workforce, financial policy or the development of infrastructure. The primary users were healthcare providers and patients, without healthcare managers or the use of data services. Most digital health interventions focused on physical therapy, bone protection and falls prevention. Limited interventions were implemented in low-and middle-income countries. CONCLUSION: A stronger evidence base is needed to expand the use of digital health for post-surgery care of hip fracture patients, including high-quality larger-scale studies, more focus in resource-constrained settings, expanding to more users and capabilities of interventions, and exploring the role of digital health for the integrated care model to mitigate health system challenges.

Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Randomized Clinical Trial.

Importance: The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence. Objective: To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older. Design, Setting, and Participants: In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses. Intervention: Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR). Main Outcomes and Measures: The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use. Results: In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02). Conclusions and Relevance: This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people. Trial Registration: http://anzctr.org.au identifier: ACTRN12616000969460.

Falls prevention interventions for community-dwelling older people living in mainland China: a narrative systematic review.

BACKGROUND: Falls in community-dwelling older people have been recognised as a significant public health issue in China given the rapidly growing aged population. Although there are several reviews documenting falls prevention programs for community-dwelling older adults, no systematic reviews of the scope and quality of falls prevention interventions in Mainland China exist. Therefore, the aim of this study was to systematically review falls prevention interventions for community-dwelling older people living in Mainland China. METHODS: We systematically reviewed literature from Chinese and English databases. All types of randomised controlled trials (RCTs) and quasi-experimental studies published from 1st January 1990 to 30th September 2019 were included. Observational studies and studies in care facilities and hospitals were excluded. Narrative synthesis was performed to summarise the key features of all included studies. Quality assessment was conducted using the Cochrane Risk of Bias Tool and ROBINS-I tool for randomised and non-randomised studies respectively. RESULTS: A total of 1020 studies were found, and 101 studies were included in the analysis. Overall, very few high quality studies were identified, and there was insufficient rigor to generate reliable evidence on the effectiveness of interventions or their scalability. Most interventions were multiple component interventions, and most studies focused on outcomes such as self-reported falls incidence or awareness of falls prevention. CONCLUSION: There is an opportunity to undertake an evaluation of a rigorously-designed, large-scale falls prevention program for community-dwelling older people in Mainland China. To help mitigate the rising burden of falls in Mainland China, recommendations for future falls prevention interventions have been made. These include: (1) target disadvantaged populations; (2) incorporate personalised interventions; and (3) investigate the effectiveness of those under-explored interventions, such as psychological, social environment, management of urinary incontinence, fluid or nutrition therapy and surgery. The study results will also potentially provide a useful evidence base for other low-and-middle income countries in a similar situation.

A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE): a statistical analyses plan.

BACKGROUND: We are performing a combined randomised and observational study comparing internal fixation to non-surgical management for common wrist fractures in older patients. This paper describes the statistical analysis plan. METHODS/DESIGN: A Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly (CROSSFIRE) is a randomised controlled trial comparing two types of usual care for treating wrist fractures in older patients, surgical fixation using volar locking plates and non-surgical treatment using closed reduction and plaster immobilisation. The primary aim of this comparative-effectiveness study is to determine whether surgery is superior to non-surgical treatment with respect to patient-reported wrist function at 12 months post treatment. The secondary outcomes include radiographic outcomes, complication rates and patient-reported outcomes including quality of life, pain, treatment success and cosmesis. Primary analysis will use a two-sample t test and an intention-to-treat analysis using the randomised arm of the study. Statistical analyses will be two-tailed and significance will be determined by p < 0.05. Sensitivity analyses will be conducted to assess for differences in intention-to-treat, per-protocol and as-treated analyses. Sensitivity analyses will also be conducted to assess selection bias by evaluating differences in participants between the randomised and observational study arms, and for bias relating to any missing data. An economic analysis will be conducted separately if surgery is shown to provide superior outcomes to a level of clinical significance. DISCUSSION: This statistical analysis plan describes the analysis of the CROSSFIRE study which aims to provide evidence to aid clinical decision-making in the treatment of distal radius fractures in older patients. TRIAL REGISTRATION: CROSSFIRE was approved by The Hunter New England Human Research Ethics Committee (HNEHREC Reference No: 16/02/17/3.04). Registered on 22 July 2016 with The Australian and New Zealand Clinical Trials Registry (ANZCTR Number; ACTRN12616000969460 ). This manuscript is based on v.11 of the statistical analysis plan. A copy of v.11, signed by the chief investigator and the senior statistician is kept at the administering institution.

Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study.

BACKGROUND: The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. METHODS: In this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. FINDINGS: Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31-62), of whom 19 937 (63·8%) were men, and 14 524 (46·5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71·9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27·5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88·7%] of 195 patients with open fractures; 426 [44·7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47·7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50·5%]), while Second Delays (delays in reaching care) were the least common (423 [5·4%]). Compared with other methods of transportation (eg, walking, rickshaw), ambulances led to delay in transporting patients with open fractures to a treating hospital (adjusted RR 0·66, 99% CI 0·46-0·93). Compared with patients with closed lower limb fractures, patients with closed spine (adjusted RR 2·47, 99% CI 2·17-2·81) and pelvic (1·35, 1·10-1·66) fractures were most likely to have delays of more than 24 h before admission to hospital. INTERPRETATION: In low-income and middle-income countries, timely hospital admission remains largely inaccessible, especially among patients with open fractures. Reducing hospital-based delays in receiving care, and, in particular, improving interfacility referral systems are the most substantial tools for reducing delays in admissions to hospital. FUNDING: National Health and Medical Research Council of Australia, Canadian Institutes of Health Research, McMaster Surgical Associates, and Hamilton Health Sciences.

Comparison of Operative Logbook Experience of Australian General Surgical Trainees With Surgeons Deployed on Humanitarian Missions: What Can Be Learnt for the Future?

OBJECTIVE: General surgical training in Australia has undergone considerable change in recent years with less exposure to other areas of surgery. General surgeons from many high-income countries have played important roles in assisting with the provision of surgical care in low- and middle-income countries during sudden-onset disasters (SODs) as part of emergency medical teams (EMTs). It is not known if contemporary Australian general surgeons are receiving the broad surgical training required for work in EMTs. DESIGN: Logbook data on the surgical procedures performed by Australian general surgical trainees were obtained from General Surgeons Australia (GSA) for the time period February 2008 to February 2017. Surgical procedures performed by Médecins sans Frontières (MSF) surgeons during 5 projects in 3 SODs (the 2010 Haiti earthquake, the 2013 Philippines typhoon and the 2015 Nepal earthquake) were obtained from previously published data for 6 months following each disaster. SETTING AND PARTICIPANTS: This was carried out at the University of Sydney with input from MSF Operational Centre Brussels and GSA. RESULTS: Australian general surgical trainees performed a mean of 2107 surgical procedures (excluding endoscopy) during their training (10 6-month rotations). Common procedures included abdominal wall hernia repairs (268, 12.7%), cholecystectomies (247, 11.8%), and specialist colorectal procedures (242, 11.5%). MSF surgeons performed a total of 3542 surgical procedures across the 5 projects analyzed. Common procedures included Caesarean sections (443, 12.5%), wound debridement (1115, 31.5%), and other trauma-related procedures (472, 13.3%). CONCLUSIONS: Australian general surgical trainees receive exposure to both essential and advanced general surgery but lack exposure to specialty procedures including the obstetric and orthopedic procedures commonly performed by MSF surgeons after SODs. Further training in these areas would likely be beneficial for general surgeons prior to deployment with an EMT.

Investigating the process of evidence-informed health policymaking in Bangladesh: a systematic review.

Over the last four decades, Bangladesh has made considerable improvements in population health, this is in part due to the use of evidence to inform policymaking. This systematic review aims to better understand critical factors that have facilitated the diffusion of scientific evidence into multiple phases of health policymaking in Bangladesh. To do this an existing policy framework designed by Shiffman and Smith in 2007, was used to extract and synthesize data from selected policy analyses. This framework was used to ensure the content, context and actors involved with evidence-informed policymaking were considered in each case where research had helped shape a health policy. The 'PRISMA Checklist' was employed to design pre-specified eligibility criteria for the selection of information sources, search strategy, inclusion and exclusion criteria, and process of data extraction and synthesis. Through our systematic search conducted from February to May 2017, we initially identified 1859 articles; after removal of duplicates, followed by the screening of titles, abstracts and full-texts, 24 articles were included in the analysis. Health policy issues included the following topics: maternal and child health, tobacco control, reproductive health, infectious disease control and the impact and sustainability of knowledge translation platforms. Findings suggested that research evidence that could be used to meet key targets associated with the Millennium Development Goals (MDGs) were more likely to be considered as a political (and therefore policy) priority. Furthermore, avenues of engagement between research organizations and the government as well as collective action from civil-society organizations were important for the diffusion of evidence into policies. Through this article, it is apparent that the interface between evidence and policy formulation occurs when evidence is, disseminated by a cohesive policy-network with strong leadership and framed to deliver solutions for problems on both the domestic and global development agenda.

Australasian general surgical training and emergency medical teams: a review.

Emergency medical teams (EMTs) have provided surgical care in sudden-onset disasters in low- and middle-income countries. General surgeons have been heavily involved in many EMTs due to their traditional broad set of surgical skills and experience. With the increased subspecialization of general surgical training in many high-income countries, including Australia and New Zealand, finding general surgeons with adequately broad experience is becoming more challenging. Furthermore, it is now considered standard for EMTs deploying to a sudden-onset disaster to have undergone credentialing, demonstrating sufficient training of their deployed members. The purpose of this review was to highlight the challenges and potential solutions facing those involved in training and recruiting general surgeons for EMTs in Australasia.

The effect of a multidisciplinary co-management program for the older hip fracture patients in Beijing: a "pre- and post-" retrospective study.

Hip fracture becomes a major public health issue with the growing aging population. This study evaluated a multidisciplinary co-management program for older hip fracture patients and found it significantly improved the best practice indicators. It provided preliminary evidence to support the use of such intervention in hip fracture management. PURPOSE/INTRODUCTION: Hip fracture leads to high morbidity and mortality in older people. A previous study found a significant disparity in hip fracture management in Beijing Jishuitan Hospital (JSTH) compared to best practice care in the United Kingdom (UK). Following this audit, JSTH launched a multidisciplinary co-management care plan for older hip fracture patients. This study aims to evaluate the effect of this program on the six standards recommended in the UK hip fracture best practice guidelines. METHODS: In this retrospective study, electronic medical record data were collected before and after the intervention. Eligible patients were aged ≥ 65 years, had X-ray confirmed hip fracture, and were admitted to JSTH within 30 days of injury. Patient demographic information, time from emergency department presentation to admission, time from admission to surgery, pressure ulcers, osteoporosis assessment, and falls prevention were collected. Multivariable logistic and median regression models were used for binary and continuous outcomes respectively. Segment regression was also performed for time-related outcomes. RESULTS: A total of 3540 eligible patients were identified. After the intervention, half of the patients who received co-management received surgery within 48 h of ward admission compared to 6.4% previously, 0.3% (vs 1.4%) developed pressure ulcers, and 76% (vs 19%) received osteoporosis assessment. No significant differences were observed in fall assessment rates. However, there was a higher rate of ward admission within 4 h of arrival in emergency for patients admitted pre-intervention (61% vs 34%). CONCLUSIONS: The introduction of the co-management model significantly reduced the time from admission to surgery and improved other practice outcomes. A multicenter randomized controlled trial is needed to evaluate the impact of this model on patient health outcomes.

Surgical Procedures Performed by Emergency Medical Teams in Sudden-Onset Disasters: A Systematic Review.

BACKGROUND: Emergency medical teams (EMTs) frequently provide surgical care after sudden-onset disasters (SODs) in low- and middle-income countries. The purpose of this review is to describe the types of surgical procedures performed by EMTs with general surgical capability in order to aid the recruitment and training of surgeons for these teams. METHODS: A search of electronic databases (PubMed, MEDLINE, and EMBASE) was carried out to identify articles published between 1990 and 2018 that describe the type of surgical procedures performed by EMTs in the impact and post-impact phases of a SOD. Further relevant articles were obtained by hand searching reference lists. RESULTS: A total of 16 articles met the inclusion criteria. Articles reporting on EMTs from a number of different countries and responding to a variety of SODs were included. There was a high prevalence of procedures for extremity soft tissue injuries (46.8%) and fractures (28.3%), although a number of abdominal and genitourinary/obstetric procedures were also reported. CONCLUSIONS: Based upon this review, deployment of surgeons or teams with experience in the management of soft tissue wounds, orthopaedic trauma, abdominal surgery, and obstetrics is recommended.

Risk factors for falls among older Aboriginal and Torres Strait Islander people in urban and regional communities.

OBJECTIVE: To examine associations between fall risk factors identified previously in other populations and falls among Aboriginal people aged 60 years and older, living in New South Wales, Australia. METHODS: Interviews were conducted with older Aboriginal people in five urban and regional communities. Associations between past falls and 22 fall predictor variables were examined using linear and multiple regression analyses. RESULTS: Of the 336 participants, 80 people (24%) reported at least one fall in the past year, and 34 (10%) reported two or more falls. Participants had an increased fall risk if they were female; used three or more medications; had arthritis, macular degeneration, depression, history of stroke; were unable to do their own housework; or were unable to do their own shopping. CONCLUSION: Falls were experienced by one-quarter of study participants. Fall risk factors identified for older Aboriginal people appear to be similar to those identified in the general population. Understanding of fall risk factors may assist with the development of appropriate and effective community-led fall prevention programs.

Visual and refractive associations with falls after first-eye cataract surgery.

PURPOSE: To clarify the effect of first-eye cataract surgery on the incidence of falls and identify components of visual function associated with fall risk. SETTING: Eight public hospital eye clinics in Sydney, Melbourne, and Perth, Australia. DESIGN: Prospective cohort study. METHODS: The study recruited patients who had bilateral cataract, were aged 65 years or older, and were on public hospital cataract surgery waiting lists. Comprehensive assessments of vision, physical function, and exercise activity were performed before and after first-eye cataract surgery. Falls were reported prospectively for up to 2 years and associations with falls were assessed using generalized linear mixed models. RESULTS: Of the 329 patients recruited, 196 (66.6%) completed first-eye surgery within the study period. First-eye cataract surgery reduced incident falls by 33% (adjusted incidence rate ratio 0.67; 95% confidence interval [CI], 0.49-0.92; P = .01). Poorer dominant-eye visual acuity was associated with falls during the study timeline (incidence rate ratio, 2.20; 95% CI, 1.02-4.74; P = .04). Patients with larger than a spherical equivalent of ±0.75 diopter change in the spectacle lens (operated eye) had a 2-fold greater incidence of falls in the period after first-eye cataract surgery than those with less or no change in lens power (incidence rate ratio, 2.17; 95% CI, 1.23-3.85; P = .008). CONCLUSIONS: First-eye cataract surgery significantly reduced incident falls. Major changes in the dioptric power of spectacle correction of the operated eye after surgery increased the fall risk. Cautious postoperative refractive management is important to maximize the benefit of cataract surgery as a fall-prevention measure.

Analysis of out-of-pocket costs associated with hospitalised injuries in Vietnam.

BACKGROUND: In Vietnam, over 39 000 people die and millions are hospitalised due to injuries every year. Injuries create a significant financial burden for families. In this study, we estimated out-of-pocket payment for medical care of injuries and the role of health insurance in containing such costs. METHOD: A prospective cohort study of 892 hospitalised injury patients admitted to a provincial general hospital in 2010 in Vietnam was conducted. Data on demographic, injury characteristics and costs by specific categories paid out-of-pocket by patients were included in the analyses. Generalised linear models with log link and γ distribution were employed to examine the associations between insurance status and total costs. RESULTS: The average total medical care costs paid out-of-pocket by patients during hospitalisation were over US$ 270. Major drivers of the costs related to surgery (nearly 25%), diagnostic test/examination (24%) and drugs (23%). Burns incurred the highest total costs during hospitalisation ($321) and assault incurred the lowest ($167). Total costs were higher for more severe injuries and those that required a more complex surgery. Patients using health insurance paid less those who did not. However, there were no statistically significant associations between health insurance and total costs, costs for surgery, diagnostic tests/examinations or drugs. CONCLUSIONS: The study provides estimates and distribution of medical care costs for injuries in hospital. In addition to ongoing efforts in prevention, the study provides further evidence on the limited benefits of health insurance in protecting patients and their family from the high costs of hospitalisation in Vietnam.

A combined randomised and observational study of surgery for fractures in the distal radius in the elderly (CROSSFIRE)-a study protocol.

Fractures of the distal radius are common and occur in all age groups. The incidence is high in older populations due to osteoporosis and increased falls risk. Considerable practice variation exists in the management of distal radius fractures in older patients ranging from closed reduction with cast immobilisation to open reduction with plate fixation. Plating is currently the most common surgical treatment. While there is evidence showing no significant advantage for some forms of surgical fixation over conservative treatment, and no difference between different surgical techniques, there is a lack of evidence comparing two of the most common treatments used: closed reduction and casting versus plating. Surgical management involves significant costs and risks compared with conservative management. High-level evidence is required to address practice variation, justify costs and to provide the best clinical outcomes for patients. METHODS AND ANALYSIS: This pragmatic, multicentre randomised comparative effectiveness trial aims to determine whether plating leads to better pain and function and is more cost-effective than closed reduction and casting of displaced distal radius fractures in adults aged 60 years and older. The trial will compare the two techniques but will also follow consenting patients who are unwilling to be randomised in a separate, observational cohort. Inclusion of non-randomised patients addresses selection bias, provides practice and outcome insights about standard care, and improves the generalisability of the results from the randomised trial. ETHICS AND DISSEMINATION: CROSSFIRE(Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly) was reviewed and approved by The Hunter New England HREC (HNEHREC Reference No: 16/02/17/3.04). The results of the trial will be published in a peer-reviewed journal and will be disseminated via various forms of media. Results will be incorporated in clinical recommendations and practice guidelines produced by professional bodies. REGISTRATION: CROSSFIRE has been registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR: ACTRN12616000969460).