Validation of a classification system for causes of death in critical care: an assessment of inter-rater reliability.

OBJECTIVE: Trials in critical care have previously used unvalidated systems to classify cause of death. We aimed to provide initial validation of a method to classify cause of death in intensive care unit patients. DESIGN, SETTING AND PARTICIPANTS: One hundred case scenarios of patients who died in an ICU were presented online to raters, who were asked to select a proximate and an underlying cause of death for each, using the ICU Deaths Classification and Reason (ICU-DECLARE) system. We evaluated two methods of categorising proximate cause of death (designated Lists A and B) and one method of categorising underlying cause of death. Raters were ICU specialists and research coordinators from Australia, New Zealand and the United Kingdom. MAIN OUTCOME MEASURES: Inter-rater reliability, as measured by the Fleiss multirater kappa, and the median proportion of raters choosing the most likely diagnosis (defined as the most popular classification choice in each case). RESULTS: Across all raters and cases, for proximate cause of death List A, kappa was 0.54 (95% CI, 0.49-0.60), and for proximate cause of death List B, kappa was 0.58 (95% CI, 0.53-0.63). For the underlying cause of death, kappa was 0.48 (95% CI, 0.44-0.53). The median proportion of raters choosing the most likely diagnosis for proximate cause of death, List A, was 77.5% (interquartile range [IQR], 60.0%-93.8%), and the median proportion choosing the most likely diagnosis for proximate cause of death, List B, was 82.5% (IQR, 60.0%-92.5%). The median proportion choosing the most likely diagnosis for underlying cause was 65.0% (IQR, 50.0%-81.3%). Kappa and median agreement were similar between countries. ICU specialists showed higher kappa and median agreement than research coordinators. CONCLUSIONS: The ICU-DECLARE system allowed ICU doctors to classify the proximate cause of death of patients who died in the ICU with substantial reliability.

The IMPACT clinic: innovative model of interprofessional primary care for elderly patients with complex health care needs.

PROBLEM ADDRESSED: The growing number of elderly patients with multiple chronic conditions presents an urgent challenge in primary care. Current practice models are not well suited to addressing the complex health care needs of this patient population. OBJECTIVE OF PROGRAM: The primary objective of the IMPACT (Interprofessional Model of Practice for Aging and Complex Treatments) clinic was to design and evaluate a new interprofessional model of care for community-dwelling seniors with complex health care needs. A secondary objective was to explore the potential of this new model as an interprofessional training opportunity. PROGRAM DESCRIPTION: The IMPACT clinic is an innovative new model of interprofessional primary care for elderly patients with complex health care needs. The comprehensive team comprises family physicians, a community nurse, a pharmacist, a physiotherapist, an occupational therapist, a dietitian, and a community social worker. The model is designed to accommodate trainees from each discipline. Patient appointments are 1.5 to 2 hours in length, during which time a diverse range of medical, functional, and psychosocial issues are investigated by the full interprofessional team. CONCLUSION: The IMPACT model is congruent with ongoing policy initiatives in primary care reform and enhanced community-based care for seniors. The clinic has been pilot-tested in 1 family practice unit and modeled at 3 other sites with positive feedback from patients and families, clinicians, and trainees. Evaluation data indicate that interprofessional primary care models hold great promise for the growing challenge of managing complex chronic disease.

The assessment and treatment of a complex geriatric patient by an interprofessional primary care team.

Mr K is an 89-year-old married man with a number of comorbid conditions and multiple recent falls. He was referred to the IMPACT clinic (Interprofessional Model of Practice for Aging and Complex Treatments) as his primary care physician was concerned about his declining health and the growing care giver burden on his wife. Mr K's condition was deteriorating while the complexity of his case was increasing; therefore, an in-depth team assessment was sought to determine the best management plan and to assess his capacity to remain at home (his expressed preference). The IMPACT team met with Mr K and his wife for a 2 h interprofessional assessment. A comprehensive care plan was developed including specific recommendations for implementing change. After the visit to the IMPACT clinic, Mr K's care was returned to his regular family physician.

Assessment of silicone polymer composites for environmental forensic applications: a proof of concept study.

This study evaluates the use of polydimethylsiloxane polymer composites (PDMS, Fe-PDMS) as a passive sampling media to preconcentrate analytes found in environmental settings. Samplers were made using commercially available silicone products. The composite samplers were assessed for their sorption properties using Atrazine and Irgarol 1051 as model compounds. The initial study assessed the utility of PDMS sheets as adsorption material by following analyte depletion from spiked water samples by solid-phase microextraction gas chromatography/mass spectrometry (GC/MS). Follow-up studies conducted at high and low concentrations using lab manufactured iron- PDMS rods (Fe-PDMS) showed effective uptake at differential rates from concentrations ranging between 1 µg/L and 10 µg/L. Adsorption mechanism was reversible, and compounds were recovered from the exposed materials and analyzed by liquid-liquid extraction-GC/MS. Both composites showed better affinity for Irgarol 1051, 100% removal, than for Atrazine, 30% removal, likely representing their K(OW) differences, 3.6 and 2.6, respectively. This "proof of concept" study demonstrates the positive implications for the use of silicon polymer composites as a monitoring tool for environmental forensic purposes.

What price do we pay to prevent alcohol-related harms in Aboriginal communities? The Alice Springs trial of liquor licensing restrictions.

This paper analyses the trial of alcohol restrictions that was implemented in Alice Springs in the Northern Territory from April 2002 to June 2003. The trial included a ban on alcohol in containers greater than 2 litres and reduced take-away trading hours. The history of the trial, its findings, and the different interpretations placed on trial data is discussed. Particular emphasis is placed on evidence indicating a link between alcohol price and consumption. Data from the evaluations of the Alice Springs trial are reviewed. The trials adds substantial new evidence to the strength of the relationship between alcohol price, consumption and harm as the restrictions led to a 1000% increase in the sale of the cheapest form of alcohol-2-litre port. Recent proposals for supply reduction strategies such as a tiered volumetric tax on alcohol and a trial of alcohol restrictions based on a minimum price benchmark demand further consideration by policy makers, especially in regions marked by a excessive alcohol consumption and a high burden of alcohol-related harms such as Alice Springs.

'Alukura ... for my daughters and their daughters and their daughters'. A review of Congress Alukura.

OBJECTIVE: To describe the process, findings and limitations of a review of Congress Alukura commissioned in 1998. METHODS: Analysis of documents and reports, service use and perinatal data from Alukura and the Northern Territory Midwives Collection; interviews with staff of Congress Alukura, of Central Australian Aboriginal Congress, of Aboriginal community organisations in Alice Springs and remote communities, of health care providers and other key informants in Alice Springs; community consultations through women's meetings or group discussions in local and remote communities. Interviews were coded for thematic and content analysis. RESULTS: Client visits increased by 42% from 1995/96 (2130) to 1997/98. The proportion of women having a first trimester antenatal visit increased from 23% (1986-88) to 38% (1993-95). Mean birthweight of Aboriginal infants in the Alice Springs urban area was 3168 g in 1986-90, 3271 g in 1991-95, and 3268 g in 1996-99. Other primary and maternity care providers perceived the quality of care to be high and saw Alukura playing a key role through transport, liaison, screening and follow-up. Alukura was much less successful in its role as a place for birth. Expectations of additional outreach by local and remote communities were high. DISCUSSION: The review's limitations included: a lack of direct input from young women, the main users of Alukura; a timeframe that precluded the detailed discussion necessary for seeking access to medical records, and the need for interpreters in community settings. Current and former staff who participated in the review often had other important community roles. Developments since the review are discussed briefly.