General practitioner assessment and management of insomnia in adults.

BACKGROUND: Sleep disturbance is among the most prevalent presentations in Australian general practice. Insomnia, the most common sleep disorder, is associated with impaired daytime, social and occupational function, reduced quality of life and substantially increased risk of future depression. Guidelines from Australian and international general practice, sleep and medical societies strongly recommend cognitive behavioural therapy for insomnia (CBT-i) as the first-line treatment for chronic insomnia. This is because CBT-i targets the underlying causes of insomnia, results in sustained improvements and commonly improves comorbid conditions such as depression and pain. OBJECTIVE: This article aims to provide an overview of evidence-based assessment, management and referral options for insomnia in Australian general practice. DISCUSSION: Access to brief insomnia assessment and evidenced-based treatments are becoming increasingly available to Australian general practitioners. CBT-i can be delivered through self-guided online programs or by suitably trained general practitioners and psychologists.

The Cost of Uncontrolled Blood Pressure in Australian General Practice: A Modelling Study Using Electronic Health Records (MedicineInsight).

BACKGROUND: Hypertension is the most common condition seen in Australian general practice. Despite hypertension being amenable to lifestyle modifications and pharmacological treatment, only around half of these patients have controlled blood pressure levels (< 140/90 mmHg), placing them at an increased risk of cardiovascular disease. OBJECTIVE: We aimed to estimate the health and acute hospitalisation costs of uncontrolled hypertension among patients attending general practice. METHODS: We used population data and electronic health records from 634,000 patients aged 45-74 years who regularly attended an Australian general practice between 2016 and 2018 (MedicineInsight database). An existing worksheet-based costing model was adapted to calculate the potential cost savings for acute hospitalisation of primary cardiovascular disease events by reducing the risk of a cardiovascular event over the next 5 years through improved systolic blood pressure control. The model estimated the number of expected cardiovascular disease events and associated acute hospital costs under current levels of systolic blood pressure and compared this estimate with the expected number of cardiovascular disease events and costs under different levels of systolic blood pressure control. RESULTS: The model estimated that across all Australians aged 45-74 years who visit their general practitioner (n = 8.67 million), 261,858 cardiovascular disease events can be expected over the next 5 years at current systolic blood pressure levels (mean 137.8 mmHg, standard deviation = 12.3 mmHg), with a cost of AUD$1813 million (in 2019-20). By reducing the systolic blood pressure of all patients with a systolic blood pressure greater than 139 mmHg to 139 mmHg, 25,845 cardiovascular disease events could be avoided with an associated reduction in acute hospital costs of AUD$179 million. If systolic blood pressure is lowered further to 129 mmHg for all those with systolic blood pressure greater than 129 mmHg, 56,169 cardiovascular disease events could be avoided with potential cost savings of AUD$389 million. Sensitivity analyses indicate that potential cost savings range from AUD$46 million to AUD$1406 million and AUD$117 million to AUD$2009 million for the two scenarios, respectively. Cost savings by practice range from AUD$16,479 for small practices to AUD$82,493 for large practices. CONCLUSIONS: The aggregate cost effects of poor blood pressure control in primary care are high, but cost implications at the individual practice level are modest. The potential cost savings improve the potential to design cost-effective interventions, but such interventions may be best targeted at a population level rather than at individual practices.

Impact of economic factors, social health and stressful life events on physical health-related quality of life trajectories in older Australians.

PURPOSE: Physical health-related quality of life (HRQoL) is associated with adverse health outcomes, including hospitalizations and all-cause mortality. However, little is known about how physical HRQoL changes over time in older people and the predictors of this trajectory. This study (a) identified trajectories of physical HRQoL among older people and (b) explored whether economic factors, social health or stressful life events impact physical HRQoL trajectories. METHOD: A cohort of 12,506 relatively 'healthy' community-dwelling Australians aged ≥ 70 years (54.4% females), enrolled in the ASPREE Longitudinal Study of Older Persons (ALSOP) study and was followed for six years. Economic factors, social health and life events in the last 12 months were assessed through a questionnaire at baseline. Physical HRQoL was measured by using the 12-item short form at baseline and annual follow-ups. Growth mixture and structural equation modelling were used to identify physical HRQoL trajectories and their predictors. RESULTS: Four physical HRQoL trajectories were identified-stable low (7.1%), declining (9.0%), stable intermediate (17.9%) and stable high (66.0%). Living in more disadvantaged areas, having a lower household income, no paid work, no voluntary work, loneliness and stressful life events (i.e. spousal illness, friend/family illness, financial problem) were associated with a 10%-152% higher likelihood of being in the stable low or declining physical HRQoL trajectory than the stable high group. CONCLUSION: Specific stressful life events had a greater impact on adverse physical HRQoL trajectories in older people than other factors. Volunteering may prevent physical HRQoL decline and requires further investigation.

Social isolation, social support and loneliness as independent concepts, and their relationship with health-related quality of life among older women.

Objectives: To assess whether social isolation, social support, and loneliness are independently associated with health-related quality of life (HRQoL).Method: Retrospective analysis including 10,517 women aged 70-75 years from the Australian Longitudinal Study on Women's Health (ALSWH). Social isolation, social support (Duke Social Support Index), and loneliness (single item) were investigated for their association with standardised HRQoL (physical [PCS] and mental [MCS] components of the SF-36® questionnaire). Analyses were adjusted for sociodemographic variables and number of medical conditions.Results: Only 3% reported being socially isolated, having low social support and being lonely, and 34% reported being not socially isolated, high social support and not being lonely. Each construct was independently associated with HRQoL, with loneliness having the strongest inverse association (PCS: isolation -0.98, low support -2.01, loneliness -2.03; MCS: isolation -1.97, low support -4.79, loneliness -10.20; p-value < 0.001 for each). Women who were not isolated or lonely and with high social support had the greatest HRQoL (compared to isolated, low social support and lonely; MCS: 17 to 18 points higher, PCS: 5 to 8 points higher). Other combinations of social isolation, social support and loneliness varied in their associations with HRQoL.Conclusion: Ageing populations face the challenge of supporting older people to maintain longer, healthy, meaningful and community-dwelling lives. Among older women, social isolation, low social support and loneliness are distinct, partially overlapping yet interconnected concepts that coexist and are each adversely associated with HRQoL. Findings should be replicated in other cohorts to ensure generalisability across other age groups and men.

Assessment, referral and management of obstructive sleep apnea by Australian general practitioners: a qualitative analysis.

BACKGROUND: The high and increasing demand for obstructive sleep apnea (OSA) care has exceeded the capacity of specialist sleep services prompting consideration of whether general practitioners could have an enhanced role in service delivery. However, little is known about the current involvement, experiences and attitudes of Australian general practitioners towards OSA. The purpose of this study was to provide an in-depth analysis of Australian general practitioners' experiences and opinions regarding their care of patients with OSA to inform the design and implementation of new general practice models of care. METHODS: Purposive sampling was used to recruit participants with maximum variation in age, experience and location. Semi-structured interviews were conducted and were analysed using Thematic Analysis. RESULTS: Three major themes were identified: (1) General practitioners are important in recognising symptoms of OSA and facilitating a diagnosis by others; (2) Inequities in access to the assessment and management of OSA; and (3) General practitioners currently have a limited role in the management of OSA. CONCLUSIONS: When consulting with patients with symptoms of OSA, general practitioners see their primary responsibility as providing a referral for diagnosis by others. General practitioners working with patients in areas of greater need, such as rural/remote areas and those of socio-economic disadvantage, demonstrated interest in being more involved in OSA management. Inequities in access to assessment and management are potential drivers for change in future models of care for OSA in general practice.

Improving access to primary health care: a cross-case comparison based on an a priori program theory.

BACKGROUND: Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative. METHODS: IMPACT's evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results. RESULTS: Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors. DISCUSSION: The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways. CONCLUSIONS: All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of 'cases'.

Implementation of a digital cognitive behavioral therapy for insomnia pathway in primary care.

Background Insomnia is a prevalent and debilitating disorder commonly managed by family physicians. Insomnia guidelines recommend cognitive behavioral therapy for insomnia (CBTi) as the 'first-line' treatment. However, family physicians report limited time, knowledge, access, support, and referral options to manage patients with CBTi. Consequently, many patients with insomnia are prescribed potentially harmful and addictive sedative-hypnotic medicines (e.g. benzodiazepines). Family physicians require an insomnia management pathway that is specifically tailored to the guideline-recommendations, time demands, and capacity of family practice. Methods This mixed-methods implementation trial will test the feasibility, acceptability and effectiveness of a comprehensive digital insomnia management pathway in family practice. This novel pathway includes digital recruitment of family physicians, automatic identification of patients whose electronic medical records contain recent sedative-hypnotic prescriptions using a software management pathway and real-time notifications prompting physicians to refer patients to a well-established digital CBTi program. At least 10 family physicians and 375 patients with insomnia will be recruited. Physicians will be provided with an eBook to guide gradual sedative-hypnotic withdrawal. Feasibility and acceptability will be assessed from the perspective of patients and physicians. Effectiveness will be determined by co-primary outcomes: cessation of sedative-hypnotic use, and improvement in self-reported insomnia symptoms from baseline to 12-month follow-up. Analysis of trends in costs, cost-effectiveness and cost-utility analyses will be conducted from a societal perspective. Results and discussion This implementation trial will pave the way for future scaling-up of this insomnia management pathway to improve access to CBTi and reduce reliance on sedative-hypnotic medicines in family practice. Trial Registration: This trial was prospectively registered on the Australian and New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12619001539123).

Burden and health state utility values of eating disorders: results from a population-based survey.

BACKGROUND: There are no published estimates of the health state utility values (HSUVs) for a broad range of eating disorders (EDs). HSUVs are used in economic evaluations to determine quality-adjusted life years or as a measure of disorder burden. The main objective of the current study is to present HSUVs for a broad range of EDs based on DSM-5 diagnoses. METHODS: We used pooled data of two Health Omnibus Surveys (2015 and 2016) including representative samples of individuals aged 15 + years living in South Australia. HSUVs were derived from the SF-6D (based on the SF-12 health-related quality of life questionnaire) and analysed by ED classification, ED symptoms (frequency of binge-eating or distress associated to binge eating) and weight status. Multiple linear regression models, adjusted for socio-demographics, were used to test the differences of HSUVs across ED groups. RESULTS: Overall, 18% of the 5609 individuals met criteria for ED threshold and subthreshold. EDs were associated with HSUV decrements, especially if they were severe disorders (compared to non-ED), binge ED: -0.16 (95% CI -0.19 to -0.13), bulimia nervosa: -0.12, (95% CI -0.16 to -0.08). There was an inverse relationship between distress related binge eating and HSUVs. HSUVs were lower among people with overweight/obese compared to those with healthy weight regardless of ED diagnosis. CONCLUSIONS: EDs were significantly associated with lower HSUVs compared to people without such disorders. This study, therefore, provides new insights into the burden of EDs. The derived HSUVs can also be used to populate future economic models.

A narrative review of the logistic and economic feasibility of cochlear implants in lower-income countries.

Objectives: Globally, less than 1% of people who could benefit from a cochlear implant have one and the problem is particularly acute in lower-income countries. Here we give a narrative review of the economic and logistic feasibility of cochlear implant programmes in lower-income countries and discuss future developments that would enable better healthcare. We review the incidence and aetiology of hearing loss in low- and middle-income countries, screening for hearing loss, implantation criteria, issues concerning imaging and surgery, and the professional expertise required. We also review the cost of cochlear implantation and ongoing costs. Findings: The cost effectiveness of cochlear implants in lower-income countries is more limited by the cost of the device than the cost of surgery, but there are also large ongoing costs that will deter many potential users. Conclusions: We conclude that the main barriers to the future uptake of cochlear implants are likely to be logistical rather than technical and cochlear implant provision should be considered as part of a wider programme to improve the health of those with hearing loss.

Does point-of-care testing in general practice for leucocyte and differential count change use of antimicrobial medicines? A pilot study.

Diagnostic uncertainty when considering prescription of antimicrobials ('antibiotics') in primary care contributes to the major problem of microbial resistance. We conducted a feasibility evaluation of rapid testing for leucocyte and differential count in two urban general practices, surveying the GPs online and interviewing them. GPs reported that the machines were easy to use, the test results influenced their care and they would adopt the system if costs were off-set. Feasibility, acceptability and perceived benefit justify a randomised trial to test the effect on antibiotic prescribing rates and quality of care, with an economic evaluation to inform the cost-benefit.

Does healthcare inequity reflect variations in peoples' abilities to access healthcare? Results from a multi-jurisdictional interventional study in two high-income countries.

BACKGROUND: Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare. METHODS: This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access. RESULTS: The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability. CONCLUSIONS: We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people's abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion.

Multimorbidity, health-related quality of life and health service use among individuals with mental health problems: Urban-rural differences in South Australia.

OBJECTIVE: To investigate urban-rural differences in the relationship between the coexistence of multiple physical health conditions, health-related quality of life and health service use among individuals with mental health problems. DESIGN: Cross-sectional. SETTING: Population-based. PARTICIPANTS: Random sample of 2977 South Australians aged 15+ years. Analyses restricted to 535 individuals self-reporting a "current" mental health problem (anxiety, depression, another mental condition). EXPOSURE: Number of physical health conditions (none, 1-2, 3+ conditions) based on a list of 16 self-reported chronic diseases. MAIN OUTCOME MEASURES: Physical and mental health-related quality of life, frequently visited a GP (3+ times), visited a mental health specialist, visited an emergency department, was hospitalised in the last 3 months. RESULTS: The mean age of the participants was 57.3 ± 13.9 years (51.9% females) with 10.6% of them living in inner regional and 14.9% in outer/remote locations. Mental health problems had similar prevalence in major cities (15.4%; 95% confidence intervals [CI]: 13.5-17.4), inner regional (19.3%; 95% CI: 14.8-24.7) and outer/remote areas (16.8%; 95% CI: 14.4-17.7). The remoteness of residence did not affect the relationship between the number of physical health conditions with health-related quality of life or visits to the emergency department/hospitalisations. Individuals without a physical health condition living in major cities were five times more likely to have frequently visited a GP than their counterparts in outer/remote South Australia (35% and 7%, respectively), but these differences were less marked among those with multiple co-morbidities. CONCLUSION: The coexistence of multiple physical health conditions among patients with a mental health problem is associated with less urban-rural disparities in terms of visiting a GP.

Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review.

BACKGROUND AND OBJECTIVE: Medication adherence is poor in patients with chronic conditions. Behavioral economic interventions may reduce biases that are associated with poor adherence. The objective of this review is to map the available evidence on behavioral economic interventions to improve medication adherence in adults with chronic conditions in high-income settings. METHODS: We conducted a scoping review and reported the study using the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Review checklist. We searched PubMed, EMBASE, SCOPUS, PsycINFO, EconLit, and CINAHL from database inception to 29 August, 2018 for peer-reviewed studies and included a search of the gray literature. Data on study characteristics, study design, and study outcomes were extracted by one reviewer. Twenty-five percent of the studies were verified by a second reviewer. RESULTS: Thirty-four studies, targeting diabetes mellitus, human immunodeficiency virus, and cardiovascular and renal diseases met our inclusion criteria. All but two studies were from the USA. The majority of interventions used financial incentives, often in conjunction with other behavioral economic concepts. Non-financial interventions included framing, social influences, reinforcement, and feedback. The effectiveness of interventions was mixed. CONCLUSIONS: Behavioral economic informed interventions show promise in terms of improving medication adherence. However, there is no single simple intervention. This review highlighted the importance of targeting non-adherent patients, understanding their reasons for non-adherence, providing reminders and feedback to patients and physicians, and measuring clinical outcomes in addition to medication adherence. Further research in settings that differ from the US health system is needed.

Improving access to primary healthcare for vulnerable populations in Australia and Canada: protocol for a mixed-method evaluation of six complex interventions.

INTRODUCTION: Access to primary healthcare (PHC) has a fundamental influence on health outcomes, particularly for members of vulnerable populations. Innovative Models Promoting Access-to-Care Transformation (IMPACT) is a 5-year research programme built on community-academic partnerships. IMPACT aims to design, implement and evaluate organisational innovations to improve access to appropriate PHC for vulnerable populations. Six Local Innovation Partnerships (LIPs) in three Australian states (New South Wales, Victoria and South Australia) and three Canadian provinces (Ontario, Quebec and Alberta) used a common approach to implement six different interventions. This paper describes the protocol to evaluate the processes, outcomes and scalability of these organisational innovations. METHODS AND ANALYSIS: The evaluation will use a convergent mixed-methods design involving longitudinal (pre and post) analysis of the six interventions. Study participants include vulnerable populations, PHC practices, their clinicians and administrative staff, service providers in other health or social service organisations, intervention staff and members of the LIP teams. Data were collected prior to and 3-6 months after the interventions and included interviews with members of the LIPs, organisational process data, document analysis and tools collecting the cost of components of the intervention. Assessment of impacts on individuals and organisations will rely on surveys and semistructured interviews (and, in some settings, direct observation) of participating patients, providers and PHC practices. ETHICS AND DISSEMINATION: The IMPACT research programme received initial ethics approval from St Mary's Hospital (Montreal) SMHC #13-30. The interventions received a range of other ethics approvals across the six jurisdictions. Dissemination of the findings should generate a deeper understanding of the ways in which system-level organisational innovations can improve access to PHC for vulnerable populations and new knowledge concerning improvements in PHC delivery in health service utilisation.

Behavioral economic insights to improve medication adherence in adults with chronic conditions: a scoping review protocol.

OBJECTIVE: The objective of this review is to map the evidence on the use of behavioral economic insights to improve medication adherence in adults with chronic conditions. INTRODUCTION: Medication non-adherence is a barrier to effectively managing chronic conditions, leading to poorer patient outcomes and placing an additional financial burden on healthcare systems. As the population ages and the prevalence of chronic disease increases, new ways to influence patient behavior are needed. Approaches that use insights from behavioral economics may help improve medication adherence, thus reducing morbidity, mortality and financial costs of unmanaged chronic diseases. INCLUSION CRITERIA: Eligible studies will include adults taking medication for a chronic condition. All interventions relevant to high-income settings using insights from behavioral economics to improve medication adherence in adults will be considered. Contexts may include, but are not limited to, primary health care, corporate wellness programs and health insurance schemes. Any study design published in English will be considered. Studies in facilities where medication is administered to patients will be excluded. METHODS: PubMed, Embase, Scopus, PsycINFO, EconLit and CINAHL will be searched from database inception to present. Gray literature will be searched using Google Scholar, OpenGrey and the Grey Literature Report. One reviewer will review titles, and then two reviewers will independently review abstracts to identify eligible studies. One reviewer will extract data on study characteristics, study design and study outcomes. A second reviewer will validate 25% of the extracted information. The results of the data extraction will be presented in a table, and a narrative summary will be presented.

Intraseason decline in influenza vaccine effectiveness during the 2016 southern hemisphere influenza season: A test-negative design study and phylogenetic assessment.

BACKGROUND: We estimated the effectiveness of seasonal inactivated influenza vaccine and the potential influence of timing of immunization on vaccine effectiveness (VE) using data from the 2016 southern hemisphere influenza season. METHODS: Data were pooled from three routine syndromic sentinel surveillance systems in general practices in Australia. Each system routinely collected specimens for influenza testing from patients presenting with influenza-like illness. Next generation sequencing was used to characterize viruses. Using a test-negative design, VE was estimated based on the odds of vaccination among influenza-positive cases as compared to influenza-negative controls. Subgroup analyses were used to estimate VE by type, subtype and lineage, as well as age group and time between vaccination and symptom onset. RESULTS: A total of 1085 patients tested for influenza in 2016 were included in the analysis, of whom 447 (41%) tested positive for influenza. The majority of detections were influenza A/H3N2 (74%). One-third (31%) of patients received the 2016 southern hemisphere formulation influenza vaccine. Overall, VE was estimated at 40% (95% CI: 18-56%). VE estimates were highest for patients immunized within two months prior to symptom onset (VE: 60%; 95% CI: 26-78%) and lowest for patients immunized >4 months prior to symptom onset (VE: 19%; 95% CI: -73-62%). DISCUSSION: Overall, the 2016 influenza vaccine showed good protection against laboratory-confirmed infection among general practice patients. Results by duration of vaccination suggest a significant decline in effectiveness during the 2016 influenza season, indicating immunization close to influenza season offered optimal protection.

Quality of Life for 19,114 participants in the ASPREE (ASPirin in Reducing Events in the Elderly) study and their association with sociodemographic and modifiable lifestyle risk factors.

PURPOSE: To explore the relationship between sociodemographic and lifestyle variables with health-related quality of life (HRQoL) of a large cohort of 'healthy' older individuals. METHODS: The sample included individuals aged 65+ years from Australia (N = 16,703) and the USA (N = 2411) enrolled in the ASPirin in Reducing Events in the Elderly (ASPREE) multicentre placebo-controlled trial study and free of cardiovascular disease, dementia, serious physical disabilities or 'fatal' illnesses. The associations with the physical (PCS) and mental component scores (MCS) of HRQoL (SF-12 questionnaire) were explored using multiple linear regression models from data collected at baseline (2010-2014). RESULTS: The adjusted PCS mean was slightly higher in the USA (49.5 ± 9.1) than Australia (48.2 ± 11.6; p < 0.001), but MCS was similar in both samples (55.7 ± 7.5 and 55.7 ± 9.6, respectively; p = 0.603). Males, younger participants, better educated, more active individuals, or those currently drinking 1-2 alcoholic drinks/day showed a better HRQoL (results more evident for PCS than MCS), while current heavy smokers had the lowest physical HRQoL in both countries. Neither age, walking time, nor alcohol intake was associated with MCS in either cohort. CONCLUSIONS: Baseline HRQoL of ASPREE participants was higher than that reported in population-based studies of older individuals, but the associations between sociodemographic and lifestyle variables were consistent with the published literature. As the cohort ages and develops chronic diseases, ASPREE will be able to document HRQoL changes.

Cost-effectiveness evaluation of the 45-49 year old health check versus usual care in Australian general practice: A modelling study.

OBJECTIVES: To assess the potential cost-effectiveness of the 45-49 year old health check versus usual care in Australian general practice using secondary data sources. METHOD: Risk factor profiles were generated for a hypothetical Australian cohort using data from the National Health Survey. Intervention effects were modelled based on a meta-analysis on risk factor changes in the 5 years after a health check. The Framingham Risk Equation was applied to estimate the 5-year cardiovascular disease (CVD) incidence in the health check and usual care group respectively. A Markov model was then constructed to extrapolate long-term CVD outcomes, health care costs and Quality Adjusted Life Years (QALYs) in both groups. Health check-related costs, applied to the health check group, were estimated from clinical guideline and experts' opinion. Lifetime costs, applied to both groups, included costs of hospitalization for CVD events and associated post-event health service use. The Incremental Cost-Effectiveness Ratio (ICER) was calculated for male and female patients respectively. RESULTS: Compared to usual care, the health check reduced CVD incidence for both males (RR = 0.87) and females (RR = 0.91) over a 5-year time. In a lifetime projection, health check led to an average 0.008 and 0.003 QALYs gained per male and female participants respectively. The estimates ICERs were AU $42,355 and AU $133,504 per QALY gained for males and females, respectively. A probabilistic sensitivity analysis demonstrated a probability of cost-effectiveness of 17.5% and 0% for male and female attendees, assuming a willingness to pay threshold of AU $28,000 per QALY gained. CONCLUSION: The 45-49 year old health check is associated with a small expected QALY gain per participant, though the persons avoiding CVD events experience large health gains. The mean ICER is larger than an empirical estimate of the threshold ICER and the evaluated health check is highly unlikely to be cost-effective.

Effectiveness of a peer-mediated educational intervention in improving general practitioner diagnostic assessment and management of dementia: a cluster randomised controlled trial.

OBJECTIVE: Test effectiveness of an educational intervention for general practitioners (GPs) on quality of life and depression outcomes for patients. DESIGN: Double-blind, cluster randomised controlled trial. SETTING: General practices in Australia between 2007 and 2010. PARTICIPANTS: General practices were randomly allocated to the waitlist (n=37) or intervention (n=66) group, in a ratio of 1:2. A total of 2030 (1478 intervention; 552 waitlist) community-dwelling participants aged 75 years or older were recruited via 168 GPs (113 intervention; 55 waitlist). INTERVENTIONS: A practice-based academic detailing intervention led by a peer educator that included: (1) training in use of the GP assessment of cognition dementia screening instrument; (2) training in diagnosis and management based on Royal Australian College of General Practitioners Dementia Guidelines; (3) addressing GPs' barriers to dementia diagnosis; and (4) a business case outlining a cost-effective dementia assessment approach. OUTCOME MEASURES: Primary outcome measures were patient quality of life and depression; secondary outcome measures were: (1) sensitivity and specificity of GP identification of dementia; (2) referral to medical specialists and/or support services; (3) patient satisfaction with care; and (4) carer quality of life, depression and satisfaction with care. RESULTS: The educational intervention had no significant effect on patient quality of life or depression scores after 12 months. There were however improvements in secondary outcome measures including sensitivity of GP judgement of dementia (p=0.002; OR 6.0, 95% CI 1.92 to 18.73), satisfaction with GP communication for all patients (p=0.024; mean difference 2.1, 95% CI 0.27 to 3.93) and for patients with dementia (p=0.007; mean difference 7.44, 95% CI 2.02 to 12.86) and enablement of carers (p=0.0185; mean difference 24.77, 95% CI 4.15 to 45.40). CONCLUSION: Practice-based academic detailing did not improve patient quality of life or depression scores but did improve detection of dementia in primary care and patient satisfaction with GP communication. TRIAL REGISTRATION NUMBER: ACTRN12607000117415; Pre-results.

Preventing chronic disease in patients with low health literacy using eHealth and teamwork in primary healthcare: protocol for a cluster randomised controlled trial.

INTRODUCTION: Adults with lower levels of health literacy are less likely to engage in health-promoting behaviours. Our trial evaluates the impacts and outcomes of a mobile health-enhanced preventive intervention in primary care for people who are overweight or obese. METHODS AND ANALYSIS: A two-arm pragmatic practice-level cluster randomised trial will be conducted in 40 practices in low socioeconomic areas in Sydney and Adelaide, Australia. Forty patients aged 40-70 years with a body mass index ≥28 kg/m2 will be enrolled per practice. The HeLP-general practitioner (GP) intervention includes a practice-level quality improvement intervention (medical record audit and feedback, staff training and practice facilitation visits) to support practices to implement the clinical intervention for patients. The clinical intervention involves a health check visit with a practice nurse based on the 5As framework (assess, advise, agree, assist and arrange), the use of a purpose-built patient-facing app, my snapp, and referral for telephone coaching. The primary outcomes are change in health literacy, lifestyle behaviours, weight, waist circumference and blood pressure. The study will also evaluate changes in quality of life and health service use to determine the cost-effectiveness of the intervention and examine the experiences of practices in implementing the programme. ETHICS AND DISSEMINATION: The study has been approved by the University of New South Wales (UNSW) Human Research Ethics Committee (HC17474) and ratified by the University of Adelaide Human Research Ethics committee. There are no restrictions on publication, and findings of the study will be made available to the public via the Centre for Primary Health Care and Equity website and through conference presentations and research publications. Deidentified data and meta-data will be stored in a repository at UNSW and made available subject to ethics committee approval. TRIAL REGISTRATIONREGISTRATION NUMBER: ACTRN12617001508369; Pre-results.