Age-Related Variation in the Provision of Primary Care Services and Medication Prescriptions for Patients with Cardiovascular Disease.

As population aging progresses, demands of patients with cardiovascular diseases (CVD) on the primary care services is inevitably increased. However, the utilisation of primary care services across varying age groups is unknown. The study aims to explore age-related variations in provision of chronic disease management plans, mental health care, guideline-indicated cardiovascular medications and influenza vaccination among patients with CVD over differing ages presenting to primary care. Data for patients with CVD were extracted from 50 Australian general practices. Logistic regression, accounting for covariates and clustering effects by practices, was used for statistical analysis. Of the 14,602 patients with CVD (mean age, 72.5 years), patients aged 65-74, 75-84 and ≥85 years were significantly more likely to have a GP management plan prepared (adjusted odds ratio (aOR): 1.6, 1.88 and 1.55, respectively, p < 0.05), have a formal team care arrangement (aOR: 1.49, 1.8, 1.65, respectively, p < 0.05) and have a review of either (aOR: 1.63, 2.09, 1.93, respectively, p < 0.05) than those < 65 years. Patients aged ≥ 65 years were more likely to be prescribed blood-pressure-lowering medications and to be vaccinated for influenza. However, the adjusted odds of being prescribed lipid-lowering and antiplatelet medications and receiving mental health care were significantly lowest among patients ≥ 85 years. There are age-related variations in provision of primary care services and pharmacological therapy. GPs are targeting care plans to older people who are more likely to have long-term conditions and complex needs.

Gender Comparison of Receipt of Government-Funded Health Services and Medication Prescriptions for the Management of Patients With Cardiovascular Disease in Primary Care.

BACKGROUND: Cardiovascular disease (CVD) and risk factors remains a major burden in terms of disease, disability, and death in the Australian population and mental health is considered as an important risk factor affecting cardiovascular disease. A multidisciplinary collaborative approach in primary care is required to ensure an optimal outcome for managing cardiovascular patients with mental health issues. Medicare introduced numerous primary care health services and medications that are subsidised by the Australian government in order to provide a more structured approach to reduce and manage CVD. However, the utilisation of these services nor gender comparison for CVD management in primary care has been explored. Therefore, the aim is to compare the provision of subsidised chronic disease management plans (CDMPs), mental health care and prescription of guideline-indicated medications to men and women with CVD in primary care practices for secondary prevention. METHODS: De-identified data for all active patients with CVD were extracted from 50 Australian primary care practices. Outcomes included the frequency of receipt of CDMPs, mental health care and prescription of evidence-based medications. Analyses adjusted for demography and clinical characteristics, stratified by gender, were performed using logistic regression and accounted for clustering effects by practices. RESULTS: Data for 14,601 patients with CVD (39.4% women) were collected. The odds of receiving the CDMPs was significantly greater amongst women than men (preparation of general practice management plan [GPMP]: (46% vs 43%; adjusted OR [95% CI]: 1.22 [1.12, 1.34]). Women were more likely to have diagnosed with mental health issues (32% vs 20%, p<0.0001), however, the adjusted odds of men and women receiving any government-subsidised mental health care were similar. Women were less often prescribed blood pressure, lipid-lowering and antiplatelet medications. After adjustment, only an antiplatelet medication or agent was less likely to be prescribed to women than men (44% vs 51%; adjusted OR [95% CI]: 0.84 [0.76, 0.94]). CONCLUSION: Women were more likely to receive CDMPs but less likely to receive antiplatelet medications than men, no gender difference was observed in the receipt of mental health care. However, the receipt of the CDMPs and the mental health treatment consultations were suboptimal and better use of these existing services could improve ongoing CVD management.

Music Therapy Private Practice in the United States: Updated Financial and Marketing Recommendations.

More and more music therapists in the United States are entering into private practice. For a private practice to survive, a therapist must make sound financial and marketing decisions that can have wide-ranging implications on the success of the business. Clear and current recommendations from music therapists in private practice can help those wanting to go into private practice as well as those already in private practice. The purpose of this study was to identify a current descriptive profile of music therapists in private practice in the United States as well as marketing and financial recommendations. In addition, comparing this survey with previous surveys can reveal possible trends in the field. Music therapists (N = 745) who self-identified as being self-employed or in private practice were sent a survey designed by the researchers. A total of 193 respondents returned the survey revealing that current therapists in private practice are better educated and value the internet and social media for marketing and session implementation more than respondents of previous surveys. Respondents recommend that music therapists in private practice continually learn by taking business classes and consulting with business experts; diversify funding sources, service options, and populations served; and connect with music therapists and nonmusic therapists in the community.

The ED2GP (emergency department to general practice) for Women study: understanding lower follow-up rates among older women.

Older women seem to have lower GP follow-up rates after an emergency department (ED) discharge than men. This qualitative study investigated how older women seek GP follow up after an ED visit. In 2018, women aged ≥65 years were recruited from an ED in a suburban hospital in south-western Sydney, Australia, and then contacted 1 week later for a telephone interview exploring factors associated with their follow-up behaviour. Grounded theory was used to construct a potential explanatory model of follow-up behaviours. Of the 100 women recruited, 64% had attended a GP follow up by Day 7, as instructed. The balance of perceived cost and benefit of GP follow up emerged as a useful model to understand the factors affecting follow-up behaviour. Perceived costs included inconvenience caused to self and others, access to transport options and the availability of a patient's GP. Perceived benefits included previous experiences with the healthcare system, pre-existing health-seeking behaviours and ED messaging. Our findings suggest that follow-up rates could be improved by strengthening the perceived benefit of GP follow up at the point of ED discharge, in addition to addressing perceived costs. Approaches may include ensuring discharge instructions are purposeful and given in the company of an older woman's social supports.

Liquid gold: the cost-effectiveness of urine sample collection methods for young precontinent children.

BACKGROUND: Urinary tract infection (UTI) is a common childhood infection. Many febrile children require a urine sample to diagnose or exclude UTI. Collecting urine from young children can be time-consuming, unsuccessful or contaminated. Cost-effectiveness of each collection method in the emergency department is unknown. OBJECTIVE: To determine the cost-effectiveness of urine collection methods for precontinent children. METHODS: A cost-effectiveness analysis was conducted comparing non-invasive (urine bag, clean catch and 5 min voiding stimulation for clean catch) and invasive (catheterisation and suprapubic aspirate (SPA)) collection methods, for children aged 0-24 months in the emergency department. Costs included equipment, staff time and hospital bed occupancy. If initial collection attempts were unsuccessful subsequent collection using catheterisation was assumed. The final outcome was a definitive sample incorporating progressive dipstick, culture and contamination results. Average costs and outcomes were calculated for initial collection attempts and obtaining a definitive sample. One-way and probabilistic sensitivity analyses were performed. RESULTS: For initial collection attempts, catheterisation had the lowest cost per successful collection (GBP£25.98) compared with SPA (£37.80), voiding stimulation (£41.32), clean catch (£52.84) and urine bag (£92.60). For definitive collection, catheterisation had the lowest cost per definitive sample (£49.39) compared with SPA (£51.84), voiding stimulation (£52.25), clean catch (£64.82) and urine bag (£112.28). Time occupying a hospital bed was the most significant determinant of cost. CONCLUSION: Catheterisation is the most cost-effective urine collection method, and voiding stimulation is the most cost-effective non-invasive method. Urine bags are the most expensive method. Although clinical factors influence choice of method, considering cost-effectiveness for this common procedure has potential for significant aggregate savings.

Alcohol screening and brief interventions in primary care - Evidence and a pragmatic practice-based approach.

BACKGROUND: Risky alcohol drinking is a common problem in adults presenting in Australian general practice. Preventive health guidelines recommend routine delivery of alcohol screening and brief intervention (ASBI) by general practitioners (GPs). However, ASBIs have rarely been implemented successfully in a sustainable manner. OBJECTIVE: In this article, we explain the current state of empirical evidence for the effectiveness of ASBI in primary care and describe a pragmatic interpretation of how this evidence applies to routine care. DISCUSSION: The empirical evidence surrounding ASBIs is complex. ASBIs are efficacious in research settings, but their effectiveness when compared with control interventions in real-world practice is less certain. Alcohol assessment within therapeutic doctor-patient relationships, rather than the specific formal tools, may be the 'active ingredient'. A pragmatic, practice-based approach to early detection of risky drinking is to focus on strategies that allow asking patients about their drinking more regularly, documenting it, and using quality improvement methodology to improve alcohol recording data completeness for the practice population.

The Impact of Environment and Occupation on the Health and Safety of Active Duty Air Force Members: Database Development and De-Identification.

Preparing data for medical research can be challenging, detail oriented, and time consuming. Transcription errors, missing or nonsensical data, and records not applicable to the study population may hamper progress and, if unaddressed, can lead to erroneous conclusions. In addition, study data may be housed in multiple disparate databases and complex formats. Merging methods may be incomplete to obtain temporally synchronized data elements. We created a comprehensive database to explore the general hypothesis that environmental and occupational factors influence health outcomes and risk-taking behavior among active duty Air Force personnel. Several databases containing demographics, medical records, health survey responses, and safety incident reports were cleaned, validated, and linked to form a comprehensive, relational database. The final step involved removing and transforming personally identifiable information to form a Health Insurance Portability and Accountability Act compliant limited database. Initial data consisted of over 62.8 million records containing 221 variables. When completed, approximately 23.9 million clean and valid records with 214 variables remained. With a clean, robust database, future analysis aims to identify high-risk career fields for targeted interventions or uncover potential protective factors in low-risk career fields.

Identifying Where REDD+ Financially Out-Competes Oil Palm in Floodplain Landscapes Using a Fine-Scale Approach.

Reducing Emissions from Deforestation and forest Degradation (REDD+) aims to avoid forest conversion to alternative land-uses through financial incentives. Oil-palm has high opportunity costs, which according to current literature questions the financial competitiveness of REDD+ in tropical lowlands. To understand this more, we undertook regional fine-scale and coarse-scale analyses (through carbon mapping and economic modelling) to assess the financial viability of REDD+ in safeguarding unprotected forest (30,173 ha) in the Lower Kinabatangan floodplain in Malaysian Borneo. Results estimate 4.7 million metric tons of carbon (MgC) in unprotected forest, with 64% allocated for oil-palm cultivations. Through fine-scale mapping and carbon accounting, we demonstrated that REDD+ can outcompete oil-palm in regions with low suitability, with low carbon prices and low carbon stock. In areas with medium oil-palm suitability, REDD+ could outcompete oil palm in areas with: very high carbon and lower carbon price; medium carbon price and average carbon stock; or, low carbon stock and high carbon price. Areas with high oil palm suitability, REDD+ could only outcompete with higher carbon price and higher carbon stock. In the coarse-scale model, oil-palm outcompeted REDD+ in all cases. For the fine-scale models at the landscape level, low carbon offset prices (US $3 MgCO2e) would enable REDD+ to outcompete oil-palm in 55% of the unprotected forests requiring US $27 million to secure these areas for 25 years. Higher carbon offset price (US $30 MgCO2e) would increase the competitiveness of REDD+ within the landscape but would still only capture between 69%-74% of the unprotected forest, requiring US $380-416 million in carbon financing. REDD+ has been identified as a strategy to mitigate climate change by many countries (including Malaysia). Although REDD+ in certain scenarios cannot outcompete oil palm, this research contributes to the global REDD+ debate by: highlighting REDD+ competitiveness in tropical floodplain landscapes; and, providing a robust approach for identifying and targeting limited REDD+ funds.

A multidisciplinary conceptualization of conservation opportunity.

An opportunity represents an advantageous combination of circumstances that allows goals to be achieved. We reviewed the nature of opportunity and how it manifests in different subsystems (e.g., biophysical, social, political, economic) as conceptualized in other bodies of literature, including behavior, adoption, entrepreneur, public policy, and resilience literature. We then developed a multidisciplinary conceptualization of conservation opportunity. We identified 3 types of conservation opportunity: potential, actors remove barriers to problem solving by identifying the capabilities within the system that can be manipulated to create support for conservation action; traction, actors identify windows of opportunity that arise from exogenous shocks, events, or changes that remove barriers to solving problems; and existing, everything is in place for conservation action (i.e., no barriers exist) and an actor takes advantage of the existing circumstances to solve problems. Different leverage points characterize each type of opportunity. Thus, unique stages of opportunity identification or creation and exploitation exist: characterizing the system and defining problems; identifying potential solutions; assessing the feasibility of solutions; identifying or creating opportunities; and taking advantage of opportunities. These stages can be undertaken independently or as part of a situational analysis and typically comprise the first stage, but they can also be conducted iteratively throughout a conservation planning process. Four types of entrepreneur can be identified (business, policy, social, and conservation), each possessing attributes that enable them to identify or create opportunities and take advantage of them. We examined how different types of conservation opportunity manifest in a social-ecological system (the Great Barrier Reef) and how they can be taken advantage of. Our multidisciplinary conceptualization of conservation opportunity strengthens and legitimizes the concept.

Synergies for improving oil palm production and forest conservation in floodplain landscapes.

Lowland tropical forests are increasingly threatened with conversion to oil palm as global demand and high profit drives crop expansion throughout the world's tropical regions. Yet, landscapes are not homogeneous and regional constraints dictate land suitability for this crop. We conducted a regional study to investigate spatial and economic components of forest conversion to oil palm within a tropical floodplain in the Lower Kinabatangan, Sabah, Malaysian Borneo. The Kinabatangan ecosystem harbours significant biodiversity with globally threatened species but has suffered forest loss and fragmentation. We mapped the oil palm and forested landscapes (using object-based-image analysis, classification and regression tree analysis and on-screen digitising of high-resolution imagery) and undertook economic modelling. Within the study region (520,269 ha), 250,617 ha is cultivated with oil palm with 77% having high Net-Present-Value (NPV) estimates ($413/ha-yr-$637/ha-yr); but 20.5% is under-producing. In fact 6.3% (15,810 ha) of oil palm is commercially redundant (with negative NPV of $-299/ha-yr-$-65/ha-yr) due to palm mortality from flood inundation. These areas would have been important riparian or flooded forest types. Moreover, 30,173 ha of unprotected forest remain and despite its value for connectivity and biodiversity 64% is allocated for future oil palm. However, we estimate that at minimum 54% of these forests are unsuitable for this crop due to inundation events. If conversion to oil palm occurs, we predict a further 16,207 ha will become commercially redundant. This means that over 32,000 ha of forest within the floodplain would have been converted for little or no financial gain yet with significant cost to the ecosystem. Our findings have globally relevant implications for similar floodplain landscapes undergoing forest transformation to agriculture such as oil palm. Understanding landscape level constraints to this crop, and transferring these into policy and practice, may provide conservation and economic opportunities within these seemingly high opportunity cost landscapes.

Appointment zen - shaping demand and matching capacity.

BACKGROUND: Ten years of experience with hundreds of general practices in the Australian Primary Care Collaboratives program has provided many lessons for improving practice appointment systems. OBJECTIVE: In this article, we describe how general practitioners can, by actively managing our appointment systems, reduce waiting times and delays, improve patient care, improve our quality of life and improve practice financial viability. DISCUSSION: Demand is finite and predictable. We can shape our demand by influencing when, why and for whom people make appointments. We can change our daily appointment numbers and our team capacity to match our reshaped demand. Contingency plans for expected and unexpected drops in capacity can prevent appointment backlogs. Embedding and monitoring our demand and capacity management can help ensure smooth flow of patients through the practice with good care and improved staff and patient satisfaction.

Evaluating local food programs: the case of Select Nova Scotia.

This study evaluated the effectiveness of the buy local food program Select Nova Scotia; a government program with the goal to increase awareness and consumption of Nova Scotia produced and processed agri-food products by Nova Scotians and visitors. The evaluation methodology was based on prior evaluation resources and local food consumer research. Data were gathered through a web panel survey; 877 respondents completed the survey in June 2010. The results suggest that the program is reaching a wider audience than just those predisposed to local food initiatives. In addition, awareness of Select Nova was related to perceptions of local benefits and barriers, as well as purchase motivation and behavior. Respondents who were aware of Select Nova Scotia rated societal benefits as more important and viewed location and price as less of a barrier; they were also more likely to be highly motivated to purchase local foods. This study also informs results found in previous consumer research studies and identifies marketing opportunities to enhance the effectiveness of local food programs. The results suggest that societal benefits might be used as a way to differentiate products with similar attributes.

Improving primary care in Australia through the Australian Primary Care Collaboratives Program: a quality improvement report.

PROBLEM: Effective and affordable health systems have good primary care. Access, equity, care of chronic conditions and quality are key priorities in primary care in Australia. DESIGN: A large-scale quality improvement collaborative addressing diabetes, coronary heart disease (CHD), access, chronic obstructive pulmonary disease (COPD), patient self-management, Aboriginal health and diabetes prevention. SETTING: General practices and Aboriginal medical services across Australia. KEY MEASURES FOR IMPROVEMENT: Sample measures are reported. STRATEGY FOR CHANGE: The Improvement Foundation (Australia) adapted collaborative strategies used in the UK. Health service teams attended three workshops, separated by activity periods and followed by 12 months of further work. Teams were supported by local collaborative program managers to make changes and report measures. Services received feedback about improvement compared with their wave. EFFECTS OF CHANGE: 1185 health services participated in 13 waves between 2005 and 2011. 83% of Australian divisions of general practice participated, and 262 support staff received quality improvement training. Key measures show improvement in all topics except access. 397,111 patients were on the disease registers of participating health services. LESSONS LEARNT: The collaborative methodology is transferable to primary care in Australia. Results may reflect improved data recording and disease coding, as well as changes in clinical care. Team dynamics and local support are important success factors. Collaboratives are a useful tool in a program of clinical quality improvement. The APCC will work with the new primary healthcare organisations which are part of health reforms in Australia to improve data reporting, improve diabetes care and entrench quality improvement in the emerging environment.

Comparison of polymer scaffolds in rat spinal cord: a step toward quantitative assessment of combinatorial approaches to spinal cord repair.

The transected rat thoracic (T(9/10)) spinal cord model is a platform for quantitatively comparing biodegradable polymer scaffolds. Schwann cell-loaded scaffolds constructed from poly (lactic co-glycolic acid) (PLGA), poly(ɛ-caprolactone fumarate) (PCLF), oligo(polyethylene glycol) fumarate (OPF) hydrogel or positively charged OPF (OPF+) hydrogel were implanted into the model. We demonstrated that the mechanical properties (3-point bending and stiffness) of OPF and OPF + hydrogels closely resembled rat spinal cord. After one month, tissues were harvested and analyzed by morphometry of neurofilament-stained sections at rostral, midlevel, and caudal scaffold. All polymers supported axonal growth. Significantly higher numbers of axons were found in PCLF (P < 0.01) and OPF+ (P < 0.05) groups, compared to that of the PLGA group. OPF + polymers showed more centrally distributed axonal regeneration within the channels while other polymers (PLGA, PCLF and OPF) tended to show more evenly dispersed axons within the channels. The centralized distribution was associated with significantly more axons regenerating (P < 0.05). Volume of scar and cyst rostral and caudal to the implanted scaffold was measured and compared. There were significantly smaller cyst volumes in PLGA compared to PCLF groups. The model provides a quantitative basis for assessing individual and combined tissue engineering strategies.

Appointments - getting it right.

BACKGROUND: Only 36% of sick Australians report being able to get an appointment on the day they need it, which is poor by international standards. This delay in care may impact on practice team morale, practice profitability and patient care. The Australian Primary Care Collaboratives Program aims to find better ways to provide primary healthcare services to patients through shared learning, peer support, training, education and support systems. OBJECTIVE: This article shares lessons from the Australian Primary Care Collaboratives Program that can help practices improve appointment scheduling. We describe steps to improving control of your practice scheduling - and your life - by measuring your practice demand, capacity and delay. DISCUSSION: Demand for appointments is finite, predictable and can be shaped. Delay is waste and the enemy of good healthcare. Where delay can be eliminated it should be. By measuring practice demand and capacity, improvements can be designed which will result in reduction in measured delay and patient unmet needs, and increased patient satisfaction.