COPD in Never-Smokers: BOLD Australia Study.

Purpose: Tobacco smoking is the major risk factor for COPD, and it is common for other risk factors in never-smokers to be overlooked. We examined the prevalence of COPD among never-smokers in Australia and identified associated risk factors. Methods: We used data from the Australia Burden of Obstructive Lung Disease (BOLD) study, a cross-section of people aged ≥40 years from six sites. Participants completed interviews and post-bronchodilator spirometry. COPD was primarily defined as an FEV1/FVC ratio <0.70 and secondarily as the ratio less than the lower limit of normal (LLN). Results: The prevalence of COPD in the 1656 never-smokers who completed the study was 10.5% (95% CI: 9.1-12.1%) [ratio

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

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

Management of Australian Adults with Bronchiectasis in Tertiary Care: Evidence-Based or Access-Driven?

PURPOSE: Australian data regarding the management of patients with bronchiectasis is scarce. We sought to compare the management of adults with bronchiectasis attending tertiary Australian centres with recent national and international guidelines. METHODS: The Australian Bronchiectasis Registry is a centralised database of patients with radiologically confirmed bronchiectasis unrelated to cystic fibrosis recruited from 14 tertiary Australian hospitals. We excluded children (<18 years) and those with incomplete data, leaving 589 adults for cross-sectional analyses. We compared the proportion of patients receiving certain therapies, as compared to the proportion eligible for those treatments according to the current guidelines and baseline clinical information available from the registry. RESULTS: Pulmonary rehabilitation was attended by 22%, although it was indicated in 67% of the cohort. Airway clearance was undertaken in 52% of patients, although 71% reported chronic productive cough. Sputum bacterial culture results were available for 59%, and mycobacterial culture results were available for 29% of the cohort. Inhaled antibiotics were used in half of potentially eligible patients. Despite guideline recommendations against routine use, inhaled corticosteroids were used in 48% of patients. Long-term macrolides were used in 28% of participants. CONCLUSIONS: Discrepancies exist between guideline recommendations and real-world treatment of bronchiectasis in Australia, even in tertiary centres. These findings suggest the need for increased patient referral to pulmonary rehabilitation, increased attention to airway clearance, increased collection of sputum samples (especially for mycobacterial culture) and rationalisation of inhaled corticosteroid use. These findings encourage a review of treatment access and will inform ongoing education to promote evidence-based care for people living with bronchiectasis.

Characteristics in Stages of Change and Decisional Balance among Smokers: The Burden of Obstructive Lung Diseases (BOLD)-Australia Study.

Smoking cessation remains a health promotion target. Applying the Transtheoretical Model to Australian Burden of Obstructive Lung Diseases (BOLD) data, we examined differences in stages of change (SoC) and readiness to quit decisional behaviours. Factors were identified likely to influence readiness of smokers, ≥40 years old, to quit. Analysis was restricted to current smokers classified to one of three stages: pre-contemplation (PC), contemplation (C) or preparation (P) to quit. Their ability to balance positive and negative consequences was measured using decisional balance. Among 314 smokers, 43.0% females and 60.8% overweight/obese, the distribution of SoC was: 38.1% PC, 38.3% C and 23.5% P. Overweight/obesity was associated with readiness to quit in stages C and P and there were more negative than positive attitudes towards smoking in those stages. Males were significantly heavier smokers in PC and C stages. Females used smoking cessation medication more frequently in PC stage, were more embarrassed about smoking and had greater negative reinforcements from smoking. Age started smoking and factors related to smoking history were associated with readiness to quit and increased the odds of being in stage C or P. An overweight/obese smoker was likely to be contemplating or preparing to quit. In these stages, smokers have more negative attitudes toward smoking. Starting smoking later, taking advice on cessation from health providers and using quit medications indicate increased readiness to quit. Evaluating these factors in smokers and developing cessation gain-framed messages may prove useful to healthcare providers.

Australian adults with bronchiectasis: The first report from the Australian Bronchiectasis Registry.

BACKGROUND: /objective: There are no large, multi-centre studies of Australians with bronchiectasis. The Australian Bronchiectasis Registry (ABR) was established in 2015 to create a longitudinal research platform. We aimed to describe the baseline characteristics of adult ABR participants and assess the impact of disease severity and exacerbation phenotype on quality of life (QoL). METHODS: The ABR is a centralised database of patients with radiologically confirmed bronchiectasis unrelated to cystic fibrosis. We analysed the baseline data of adult patients (≥18 years). RESULTS: From March 2016-August 2018, 799 adults were enrolled from 14 Australian sites. Baseline data were available for 589 adults predominantly from six tertiary centres (420 female, median age 71 years (interquartile range 64-77), 14% with chronic Pseudomonas aeruginosa infection). Most patients had moderate or severe disease based on the Bronchiectasis Severity Index (BSI) (84%) and FACED (59%) composite scores. Using Global Lung function Initiative-2012 reference equations, the majority of patients (48%) had normal spirometry; only 34% had airflow obstruction (FEV1/FVC < LLN). Disease severity scores (BSI and FACED) were negatively correlated with QoL-Bronchiectasis domain scores (rs between -0.09 and -0.58). The frequent exacerbator phenotype (≥3 in the preceding year) was identified in 23%; this group had lower scores in all QoL-B domains (p ≤ 0.001) and more hospitalisations (p < 0.001) than those with <3 exacerbations. CONCLUSIONS: The largest cohort of Australian adults with bronchiectasis has been described. Using contemporary criteria, most patients with bronchiectasis did not have airflow obstruction. The frequent exacerbation trait connotes poorer QoL and greater health-care utilisation.

A comparison of two malnutrition screening tools in acute medical inpatients and validation of a screening tool among adult Indigenous Australian patients.

BACKGROUND AND OBJECTIVES: The objectives of this study were to identify and validate a screening tool to detect malnutrition among Indigenous and non-Indigenous Australian patients. METHODS AND STUDY DESIGN: This study included medical patients admitted into three regional hospitals in Australia. A literature review was undertaken of current screening tools before the Malnutrition Screening Tool (MST) and the newly developed Adult Nutrition Tool (ANT) were used to validate a screening tool for use among participants against the Subjective Global Assessment (SGA) tool. The sensitivity and specificity of both the MST and ANT were determined for all study participants as well as according to participants' Indigenous status. RESULTS: A total of 608 participants were enrolled into the study, of whom 271 (44.6%) were Indigenous. The area under the curve (AUC) when utilising ANT was higher in all participants compared to the MST (0.90, 95% CI 0.88-0.92 versus 0.81, 95% CI 0.77-0.84, p<0.001). The AUC was also significantly higher for Indigenous participants when utilising ANT compared to the MST (0.88, 95% CI 0.84-0.92 versus 0.78, 95% CI 0.73-0.83, p<0.001). An ANT >=2 demonstrated superior sensitivity for both Indigenous and non-Indigenous participants (96.0%, 95% CI 92.8-98.7%) than the MST (84.0%, 95% CI 78.9-88.3) but with inferior specificity (59.5%, 95% CI 54.2-64.6) than the MST (70.7%, 95% CI 65.7-75.3). CONCLUSIONS: The ANT is both a valid and accurate tool for Indigenous and non-Indigenous Australian patients. Further research is required to validate ANT to aide in the detection of malnutrition in other clinical settings.

Bronchiectasis in indigenous and non-indigenous residents of Australia and New Zealand.

BACKGROUND AND OBJECTIVE: Bronchiectasis not associated with cystic fibrosis is an increasingly recognized chronic lung disease. In Oceania, indigenous populations experience a disproportionately high burden of disease. We aimed to describe the natural history of bronchiectasis and identify risk factors associated with premature mortality within a cohort of Aboriginal Australians, New Zealand Maori and Pacific Islanders, and non-indigenous Australians and New Zealanders. METHODS: This was a retrospective cohort study of bronchiectasis patients aged >15 years at three hospitals: Alice Springs Hospital and Monash Medical Centre in Australia, and Middlemore Hospital in New Zealand. Data included demographics, ethnicity, sputum microbiology, radiology, spirometry, hospitalization and survival over 5 years of follow-up. RESULTS: Aboriginal Australians were significantly younger and died at a significantly younger age than other groups. Age- and sex-adjusted all-cause mortality was higher for Aboriginal Australians (hazard ratio (HR): 3.9), and respiratory-related mortality was higher for both Aboriginal Australians (HR: 4.3) and Maori and Pacific Islander people (HR: 1.7). Hospitalization was common: Aboriginal Australians had 2.9 admissions/person-year and 16.9 days in hospital/person-year. Despite Aboriginal Australians having poorer prognosis, calculation of the FACED score suggested milder disease in this group. Sputum microbiology varied with Aspergillus fumigatus more often isolated from non-indigenous patients. Airflow obstruction was common (66.9%) but not invariable. CONCLUSIONS: Bronchiectasis is not one disease. It has a significant impact on healthcare utilization and survival. Differences between populations are likely to relate to differing aetiologies and understanding the drivers of bronchiectasis in disadvantaged populations will be key.

Outcome following valve surgery in Australia: development of an enhanced database module.

BACKGROUND: Valvular heart disease, including rheumatic heart disease (RHD), is an important cause of heart disease globally. Management of advanced disease can include surgery and other interventions to repair or replace affected valves. This article summarises the methodology of a study that will incorporate enhanced data collection systems to provide additional insights into treatment choice and outcome for advanced valvular disease including that due to RHD. METHODS: An enhanced data collection system will be developed linking an existing Australian cardiac surgery registry to more detailed baseline co-morbidity, medication, echocardiographic and hospital separation data to identify predictors of morbidity and mortality outcome following valve surgery. DISCUSSION: This project aims to collect and incorporate more detailed information regarding pre and postoperative factors and subsequent morbidity. We will use this to provide additional insights into treatment choice and outcome.

The burden and implications of preoperative atrial fibrillation in Australian heart valve surgery patients.

BACKGROUND: Atrial fibrillation (AF) is the most common preoperative arrhythmia in heart valve surgery patients and its prevalence is rising. This study aims to investigate the impact of AF on valve surgery early complications and survival and on valve disease of different aetiologies and populations with particular reference to Indigenous Australians with rheumatic heart disease (RHD). METHODS: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to determine the association between preoperative AF and valve surgery outcome. Its association with demographics, co-morbidities, preoperative status and short and long term outcome was assessed. RESULTS: Outcome of 1594 RHD and 19,029 non-RHD-related surgical procedures was analysed. Patients with preoperative AF were more likely to be older, female, Indigenous, to have RHD and to bear a greater burden of comorbidities. Patients with RHD and preoperative AF had a longer hospital stay and were more likely to require reoperation. Adjusted short (OR 1.4, 95% CI 1.2-1.7) and long term (HR 1.5, 95% CI 1.3-1.7) survival was inferior for patients with non-RHD preoperative AF but was no different for Indigenous and non-Indigenous Australians with RHD. CONCLUSIONS: In this prospective Australian study, patients with valve disease and preoperative AF had inferior short and long term survival. This was particularly the case for patients with non-RHD valve disease. Earlier intervention or more aggressive AF management should be investigated as mechanisms for enhancing postoperative outcomes. This may influence treatment choice and the need for ongoing anticoagulation.

Outcomes after mitral valve surgery for rheumatic heart disease.

OBJECTIVE: To further the understanding of the factors influencing outcome following rheumatic heart disease (RHD) related mitral valve surgery, which globally remains an important cause of heart disease and a particular problem in Indigenous Australians. METHODS: The Australian Cardiac Surgery Database was utilised to assess outcomes following mitral valve repair and replacement for RHD and non-RHD valve disease. The association with aetiology, demographics, comorbidities, preoperative status and operative procedure was evaluated. RESULTS: Mitral valve repairs and replacements undertaken in Australia were analysed from 119 and 1078 RHD surgical procedures and 3279 and 2400 non-RHD procedures, respectively. RHD mitral valve repair, compared with replacement, resulted in a slightly shorter hospital stay and more reoperation for valve dysfunction, but no difference in 30-day survival. In unadjusted survival analysis to 5 years, RHD mitral valve repair and replacement were no different (HR 0.86, 95% CI 0.4 to 1.7), non-RHD repair was superior to replacement (HR 1.7, 95% CI 1.4 to 2.0), RHD and non-RHD repair were no different (HR 0.9, 95% CI 0.5 to 1.7), and RHD replacement was superior to non-RHD (HR 1.5, 95% CI 1.2 to 1.9). None of these differences persisted in adjusted analyses and there was no difference in long-term survival for Indigenous Australians. CONCLUSION: In this large prospective cohort study we have demonstrated that adjusted long-term survival following RHD mitral valve repair surgery in Australia is no different to replacement and no different to non-RHD. Interpretation of valve surgery outcome requires careful consideration of patient factors that may also influence survival.

Case load and valve surgery outcome in Australia.

BACKGROUND: In Australia it has been suggested that heart valve surgery, particularly for rheumatic heart disease (RHD), should be consolidated in higher volume centres. International studies of cardiac surgery suggest large volume centres have superior outcomes. However the effect of site and surgeon case load on longer term outcomes for valve surgery has not been investigated. METHODS: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed. The adjusted association between both average annual site and surgeon case load on short term complications and short and long-term survival was determined. RESULTS: Outcomes associated with 20,116 valve procedures at 25 surgical sites and by 93 surgeons were analysed. Overall adjusted analysis showed increasing site and surgeon case load was associated with longer ventilation, less reoperation and more anticoagulant complications. Increasing surgeon case load was also associated with less acute kidney injury. Adjusted 30-day mortality was not associated with site or surgeon case load. There was no consistent relationship between increasing site case load and long term survival. The association between surgeon case load and outcome demonstrated poorer adjusted survival in the highest volume surgeon group. CONCLUSIONS: In this Australian study, the adjusted association between surgeon and site case load was not simple or consistent. Overall larger volume sites or surgeons did not have superior outcomes. Mandating a particular site case load level for valve surgery or a minimum number of procedures for individual surgeons, in an Australian context, cannot be supported by these findings.

A review of outcome following valve surgery for rheumatic heart disease in Australia.

BACKGROUND: Globally, rheumatic heart disease (RHD) remains an important cause of heart disease. In Australia it particularly affects younger Indigenous and older non-Indigenous Australians. Despite its impact there is limited understanding of the factors influencing outcome following surgery for RHD. METHODS: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed to assess outcomes following surgical procedures for RHD and non-RHD valvular disease. The association with demographics, co-morbidities, pre-operative status, valve(s) affected and operative procedure was evaluated. RESULTS: Outcome of 1384 RHD and 15843 non-RHD valve procedures was analysed. RHD patients had longer ventilation, experienced fewer strokes and had more readmissions to hospital and anticoagulant complications. Mortality following RHD surgery at 30 days was 3.1% (95% CI 2.2 - 4.3), 5 years 15.3% (11.7 - 19.5) and 10 years 25.0% (10.7 - 44.9). Mortality following non-RHD surgery at 30 days was 4.3% (95% CI 3.9 - 4.6), 5 years 17.6% (16.4 - 18.9) and 10 years 39.4% (33.0 - 46.1). Factors independently associated with poorer longer term survival following RHD surgery included older age (OR1.03/additional year, 95% CI 1.01 - 1.05), concomitant diabetes (OR 1.7, 95% CI 1.1 - 2.5) and chronic kidney disease (1.9, 1.2 - 2.9), longer invasive ventilation time (OR 1.7 if greater than median value, 1.1- 2.9) and prolonged stay in hospital (1.02/additional day, 1.01 - 1.03). Survival in Indigenous Australians was comparable to that seen in non-Indigenous Australians. CONCLUSION: In a large prospective cohort study we have demonstrated survival following RHD valve surgery in Australia is comparable to earlier studies. Patients with diabetes and chronic kidney disease, were at particular risk of poorer long-term survival. Unlike earlier studies we did not find pre-existing atrial fibrillation, being an Indigenous Australian or the nature of the underlying valve lesion were independent predictors of survival.

Prevalence of airflow obstruction and reduced forced vital capacity in an Aboriginal Australian population: The cross-sectional BOLD study.

BACKGROUND AND OBJECTIVE: Mortality and hospital separation data suggest a higher burden of chronic obstructive pulmonary disease (COPD) in indigenous than non-indigenous subpopulations of high-income countries. This study sought to accurately measure the true prevalence of post-bronchodilator airflow obstruction and forced vital capacity reduction in representative samples of Indigenous and non-Indigenous Australians. METHODS: This study applies cross-sectional population-based survey of Aboriginal and non-Indigenous residents of the Kimberley region of Western Australia aged 40 years or older, following the international Burden Of Lung Disease (BOLD) protocol. Quality-controlled spirometry was conducted before and after bronchodilator. COPD was defined as Global initiative for chronic Obstructive Lung Disease (GOLD) Stage 2 and above (post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1 /FVC) ratio <0.7 and FEV1 < 80% predicted). RESULTS: Complete data were available for 704 participants. The prevalence of COPD, adjusted for age, gender and body weight in Aboriginal participants (7.2%, 95% confidence interval (CI) 3.9 to 10.4) was similar to that seen in non-Indigenous Kimberley participants (8.2%, 95% CI 5.7 to 10.7) and non-Indigenous residents of the remainder of Australia (7.1%, 95% CI 6.1 to 8.0). The prevalence of low FVC (<80% predicted) was substantially higher in Aboriginal compared with non-Indigenous participants (74.0%, 95% CI 69.1 to 78.8, vs 9.7%, 95% CI 7.1 to 12.4). CONCLUSIONS: Low FVC, rather than airflow obstruction, characterizes the impact of chronic lung disease previously attributed to COPD in this population subject to significant social and economic disadvantage. Environmental risk factors other than smoking as well as developmental factors must be considered. These findings require further investigation and have implications for future prevention of chronic lung disease in similar populations.

Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening.

OBJECTIVES: To compare regional differences in the prevalence of rheumatic heart disease (RHD) detected by echocardiographic screening in high-risk Indigenous Australian children, and to describe the logistical and other practical challenges of RHD screening. DESIGN: Cross-sectional screening survey performed between September 2008 and November 2010. SETTING: Thirty-two remote communities in four regions of northern and central Australia. PARTICIPANTS: 3946 Aboriginal or Torres Strait Islander children aged 5-15 years. INTERVENTION: Portable echocardiography was performed by cardiac sonographers. Echocardiograms were recorded and reported offsite by a pool of cardiologists. MAIN OUTCOME MEASURES: RHD was diagnosed according to 2012 World Heart Federation criteria. RESULTS: The prevalence of definite RHD differed between regions, from 4.7/1000 in Far North Queensland to 15.0/1000 in the Top End of the Northern Territory. The prevalence of definite RHD was greater in the Top End than in other regions (odds ratio, 2.3; 95% CI, 1.2-4.6, P = 0.01). Fifty-three per cent of detected cases of definite RHD were new cases; the prevalence of new cases of definite RHD was 4.6/1000 for the entire sample and 7.0/1000 in the Top End. Evaluation of socioeconomic data suggests that the Top End group was the most disadvantaged in our study population. CONCLUSIONS: The prevalence of definite RHD in remote Indigenous Australian children is significant, with a substantial level of undetected disease. Important differences were noted between regions, with the Top End having the highest prevalence of definite RHD, perhaps explained by socioeconomic factors. Regional differences must be considered when evaluating the potential benefit of widespread echocardiographic screening in Australia.

Assessing the performance of two lung age equations on the Australian population: using data from the cross-sectional BOLD-Australia study.

INTRODUCTION: Lung age, a simple concept for patients to grasp, is frequently used as an aid in smoking cessation programs. Lung age equations should be continuously updated and should be made relevant for target populations. We observed how new lung age equations developed for Australian populations performed when utilizing the Burden of Obstructive Lung Disease (BOLD)-Australia dataset compared to more commonly used equations. METHODS: Data from a cross-sectional population study of noninstitutionalized Australians aged ≥40 years with analysis restricted to Caucasians <75 years. Lung age calculated using equations developed by Newbury et al. and Morris and Temple was compared with chronological age by smoking status and within smoking status. RESULTS: There were 2,793 participants with a mean age of 57 (±10 SD) years. More than half (52%) ever smoked, and 10.4% were current smokers. Prevalence of chronic obstructive pulmonary disease stage I or higher was 13.4% (95% confidence interval = 12.2, 14.7). For both genders, newer Newbury equations estimated lung ages significantly higher than actual age across all smoking groups (p < .05). Morris and Temple equations resulted in lung age estimates significantly lower than chronological age for nonsmokers (p < .05) but no difference among current smokers. Both equations showed exposure to smoking had lung ages higher than never-smokers (p < .001). Lung age also increased with increased pack-years. CONCLUSIONS: This supports the use of updated equations suited to the population of interest. The Australian Newbury equations performed well in the BOLD-Australia dataset, providing more meaningful lung age profile compared to chronological age among smokers. Using equations not developed or ideally suited for our population is likely to produce misleading results.

Clinical trials in a remote Aboriginal setting: lessons from the BOABS smoking cessation study.

BACKGROUND: There is limited evidence regarding the best approaches to helping Indigenous Australians to stop smoking. The composite analysis of the only two smoking cessation randomised controlled trials (RCTs) investigating this suggests that one-on-one extra support delivered by and provided to Indigenous Australians in a primary health care setting appears to be more effective than usual care in encouraging smoking cessation. This paper describes the lessons learnt from one of these studies, the Be Our Ally Beat Smoking (BOABS) Study, and how to develop and implement an integrated smoking cessation program. METHODS: Qualitative study using data collected from multiple documentary sources related to the BOABS Study. As the project neared completion the research team participated in four workshops to review and conduct thematic analyses of these documents. RESULTS: Challenges we encountered during the relatively complex BOABS Study included recruiting sufficient number of participants; managing the project in two distant locations and ensuring high quality work across both sites; providing appropriate training and support to Aboriginal researchers; significant staff absences, staff shortages and high workforce turnover; determining where and how the project fitted in the clinics and consequent siloing of the Aboriginal researchers relating to the requirements of RCTs; resistance to change, and maintaining organisational commitment and priority for the project. The results of this study also demonstrated the importance of local Aboriginal ownership, commitment, participation and control. This included knowledge of local communities, the flexibility to adapt interventions to local settings and circumstances, and taking sufficient time to allow this to occur. CONCLUSIONS: The keys to the success of the BOABS Study were local development, ownership and participation, worker professional development and support, and operating within a framework of cultural safety. There were difficulties associated with the BOABS Study being an RCT, and many of these are shared with stand-alone programs. Interventions targeted at particular health problems are best integrated with usual primary health care. Research to investigate complex interventions in Indigenous health should not be limited to randomised clinical trials and funding needs to reflect the additional, but necessary, cost of providing for local control of planning and implementation.

The Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote aboriginal Australian health care setting.

BACKGROUND: Australian Aboriginal and Torres Strait Islander peoples (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the outcome of a study that aimed to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program. METHODS: A randomised controlled trial of Aboriginal researcher delivered tailored smoking cessation counselling during face-to-face visits, aiming for weekly for the first four weeks, monthly to six months and two monthly to 12 months. The control ("usual care") group received routine care relating to smoking cessation at their local primary health care service. Data collection occurred at enrolment, six and 12 months. The primary outcome was self-reported smoking cessation with urinary cotinine confirmation at final follow-up (median 13 (interquartile range 12-15) months after enrolment). RESULTS: Participants in the intervention (n = 55) and usual care (n = 108) groups were similar in baseline characteristics, except the intervention group was slightly older. At final follow-up the smoking cessation rate for participants assigned to the intervention group (n = 6; 11%), while not statistically significant, was double that of usual care (n = 5; 5%; p = 0.131). A meta-analysis of these findings and a similarly underpowered but comparable study of pregnant Indigenous Australian women showed that Indigenous Australian participants assigned to the intervention groups were 2.4 times (95% CI, 1.01-5.5) as likely to quit as participants assigned to usual care. CONCLUSIONS: Culturally appropriate, multi-dimensional Indigenous quit smoking programs can be successfully implemented in remote primary health care. Intensive one-on-one interventions with substantial involvement from Aboriginal and Torres Strait Islander workers are likely to be effective in these settings. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12608000604303).

Utility of auscultatory screening for detecting rheumatic heart disease in high-risk children in Australia's Northern Territory.

OBJECTIVES: To evaluate the utility of auscultatory screening for detecting echocardiographically confirmed rheumatic heart disease (RHD) in high-risk children in the Northern Territory, Australia. DESIGN: Cross-sectional screening survey. SETTING: Twelve rural and remote communities in the NT between September 2008 and June 2010. PARTICIPANTS: 1015 predominantly Indigenous schoolchildren aged 5-15 2013s. INTERVENTION: All children underwent transthoracic echocardiography, using a portable cardiovascular ultrasound machine, and cardiac auscultation by a doctor and a nurse. Sonographers and auscultators were blinded to each others' findings and the clinical history of the children. Echocardiograms were reported offsite, using a standardised protocol, by cardiologists who were also blinded to the clinical findings. MAIN OUTCOME MEASURES: Presence of a cardiac murmur as identified by nurses (any murmur) and doctors (any murmur, and "suspicious" or "pathological" murmurs), compared with echocardiogram findings. RHD was defined according to the 2012 World Heart Federation criteria for echocardiographic diagnosis of RHD. RESULTS: Of the 1015 children screened, 34 (3.3%) had abnormalities identified on their echocardiogram; 24 met echocardiographic criteria for definite or borderline RHD, and 10 had isolated congenital anomalies. Detection of any murmur by a nurse had a sensitivity of 47.1%, specificity of 74.8% and positive predictive value (PPV) of 6.1%. Doctor identification of any murmur had 38.2% sensitivity, 75.1% specificity and 5.1% PPV, and the corresponding values for doctor detection of suspicious or pathological murmurs were 20.6%, 92.2% and 8.3%. For all auscultation approaches, negative predictive value was more than 97%, but the majority of participants with cardiac abnormalities were not identified. The results were no different when only definite RHD and congenital abnormalities were considered as true cases. CONCLUSIONS: Sensitivity and positive predictive value of cardiac auscultation compared with echocardiography is poor, regardless of the expertise of the auscultator. Although negative predictive value is high, most cases of heart disease were missed by auscultation, suggesting that cardiac auscultation should no longer be used to screen for RHD in high-risk schoolchildren in Australia.

Utility of exercise electrocardiography testing for the diagnosis of coronary artery disease in a remote Australian setting.

OBJECTIVE: To determine the utility of exercise electrocardiography testing (EET) in evaluating suspected coronary artery disease in a remote Australian setting where a significant proportion of patients are Indigenous Australians. DESIGN: Retrospective cohort study with grouping based on EET results. PATIENTS AND SETTING: 268 patients with suspected coronary artery disease who underwent EET at Alice Springs Hospital--a specialist teaching hospital in Central Australia with no resident specialist cardiology service--in the period 1 June 2009 to 31 May 2010. MAIN OUTCOME MEASURES: Diagnosis of coronary artery disease, based on coronary angiography and/or admission with acute coronary syndrome, in the 24 months after EET. RESULTS: Indigenous patients were younger, more likely to be women and were twice as likely as non-Indigenous patients to have a chronic disease. Indigenous patients and those with a chronic disease had a higher proportion of inconclusive results. Completed EET had a positive predictive value of 48.1% (95% CI, 28.7%-68.1%) and a negative predictive value of 96.5% (95% CI, 93.2%-98.5%). Similar results were seen among Indigenous and non-Indigenous patients. CONCLUSIONS: In regional and remote Australian settings, EET remains an important tool for the diagnosis of coronary artery disease. It is useful, and is reassuring to patients and clinicians if the result is negative, particularly in a remote Indigenous Australian population with a significant burden of cardiovascular risk.