Evaluating a shared care pathway intervention for people receiving chemotherapy to reduce post-treatment unplanned hospital presentations: a randomised controlled trial.

PURPOSE: The aim of this randomised controlled trial (RCT) was to explore whether a community nursing intervention for outpatients receiving systemic therapy reduced unplanned hospital presentations and improved physical and psychosocial health outcomes over the first three cycles of treatment compared to a control group receiving standard care. METHODS: The number of and reasons for unplanned presentations were obtained for 170 intervention and 176 control group adult patients with solid tumours starting outpatient chemotherapy. Poisson regression was used to compare the number of presentations between the intervention and control groups. Patients self-completed the Hospital Anxiety and Depression Scale, the Cancer Behavior Inventory and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire core 30 (EORTC QLQ-C30) at the start of the first four cycles. Linear regression techniques were used to compare quality of life outcomes. RESULTS: The reduction in unplanned presentations in the intervention group relative to the control group was 12% (95% CI, - 25%, 37%; P = 0.48). At the start of cycle 4, there was no difference in anxiety (difference = 0.47 (95% CI, - 0.28, 1.22; P = 0.22)), depression (difference = 0.57 (95% CI, - 0.18, 1.31; P = 0.13)) or EORTC QLQ-C30 summary score (difference = 0.16 (95% CI, - 2.67, 3.00; P = 0.91)). Scores for self-efficacy as measured by the Cancer Behavior Inventory were higher in the intervention group (difference = 4.3 (95% CI, 0.7, 7.9; P = 0.02)). CONCLUSION: This RCT did not demonstrate a benefit in reducing unplanned presentations to hospital. The trial identified improved cancer-based self-efficacy in patients receiving the intervention. TRIAL REGISTRATION: Registered at Australian and New Zealand Clinical Trials Registry: ACTRN12614001113640, registered 21/10/2014.

Burnout and distress in Australian physician trainees: Evaluation of a wellbeing workshop.

OBJECTIVE: To evaluate the effectiveness of a workshop intervention to promote wellbeing for Australian physician trainees using a randomized-controlled design. METHODS: Participants were randomly assigned into intervention and control groups. The intervention group attended a half-day workshop. Outcome measures included depression anxiety stress scale, professional quality of life scale and alcohol use disorders identification test. Demographic and work/life factors were measured. Measurements were recorded at baseline, 3 and 6 months, and the workshop was evaluated by participants. RESULTS: High rates of burnout (76%) and secondary traumatic stress (91%) were detected among study participants and around half met screening criteria for depression (52%), anxiety (46%) and stress (50%) at baseline. Workshop evaluations showed that participants agreed that the training was relevant to their needs (96%) and met their expectations (92%). There was a small reduction in alcohol use, depression and burnout in the intervention group compared with the control group at 6 months, but these changes did not reach statistical significance. CONCLUSION: High rates of psychological morbidity detected in the study suggest that physician trainees are a vulnerable group who may benefit from initiatives that promote wellbeing and changes in the workplace to reduce distress.

Health care professionals' attitudes towards evidence-based medicine in the workers' compensation setting: a cohort study.

BACKGROUND: Problems may arise during the approval process of treatment after a compensable work injury, which include excess paperwork, delays in approving services, disputes, and allegations of over-servicing. This is perceived as undesirable for injured people, health care professionals and claims managers, and costly to the health care system, compensation system, workplaces and society. Introducing an Evidence Based Medicine (EBM) decision tool in the workers' compensation system could provide a partial solution, by reducing uncertainty about effective treatment. The aim of this study was to investigate attitudes of health care professionals (HCP) to the potential implementation of an EBM tool in the workers' compensation setting. METHODS: The study has a mixed methods design. The quantitative study consisted of an online questionnaire asking about self-reported knowledge, attitudes and behaviour to EBM in general. The qualitative study consisted of interviews about an EBM tool being applied in the workers' compensation process. Participants were health care practitioners from different clinical specialties. They were recruited through the investigators' clinical networks and the workers' compensation government regulator's website. RESULTS: Participants completing the questionnaire (n = 231) indicated they were knowledgeable about the evidence-base in their field, but perceived some difficulties when applying EBM. General practitioners reported having the greatest obstacles to applying EBM. Participants who were interviewed (n = 15) perceived that an EBM tool in the workers' compensation setting could potentially have some advantages, such as reducing inappropriate treatment, or over-servicing, and providing guidance for clinicians. However, participants expressed substantial concerns that the EBM tool would not adequately reflect the impact of psychosocial factors on recovery. They also highlighted a lack of timeliness in decision making and proper assessment, particularly in pain management. CONCLUSIONS: Overall, HCP are supportive of EBM, but have strong concerns about implementation of EBM based decision making in the workers' compensation setting. The participants felt that an EBM tool should not be applied rigidly and should take into account clinical judgement and patient variability and preferences. In general, the treatment approval process in the workers' compensation insurance system is a sensitive area, in which the interaction between HCP and claims managers can be improved.

Land cover change and carbon emissions over 100 years in an African biodiversity hotspot.

Agricultural expansion has resulted in both land use and land cover change (LULCC) across the tropics. However, the spatial and temporal patterns of such change and their resulting impacts are poorly understood, particularly for the presatellite era. Here, we quantify the LULCC history across the 33.9 million ha watershed of Tanzania's Eastern Arc Mountains, using geo-referenced and digitized historical land cover maps (dated 1908, 1923, 1949 and 2000). Our time series from this biodiversity hotspot shows that forest and savanna area both declined, by 74% (2.8 million ha) and 10% (2.9 million ha), respectively, between 1908 and 2000. This vegetation was replaced by a fivefold increase in cropland, from 1.2 million ha to 6.7 million ha. This LULCC implies a committed release of 0.9 Pg C (95% CI: 0.4-1.5) across the watershed for the same period, equivalent to 0.3 Mg C ha(-1)  yr(-1) . This is at least threefold higher than previous estimates from global models for the same study area. We then used the LULCC data from before and after protected area creation, as well as from areas where no protection was established, to analyse the effectiveness of legal protection on land cover change despite the underlying spatial variation in protected areas. We found that, between 1949 and 2000, forest expanded within legally protected areas, resulting in carbon uptake of 4.8 (3.8-5.7) Mg C ha(-1) , compared to a committed loss of 11.9 (7.2-16.6) Mg C ha(-1) within areas lacking such protection. Furthermore, for nine protected areas where LULCC data are available prior to and following establishment, we show that protection reduces deforestation rates by 150% relative to unprotected portions of the watershed. Our results highlight that considerable LULCC occurred prior to the satellite era, thus other data sources are required to better understand long-term land cover trends in the tropics.

An integrated pan-tropical biomass map using multiple reference datasets.

We combined two existing datasets of vegetation aboveground biomass (AGB) (Proceedings of the National Academy of Sciences of the United States of America, 108, 2011, 9899; Nature Climate Change, 2, 2012, 182) into a pan-tropical AGB map at 1-km resolution using an independent reference dataset of field observations and locally calibrated high-resolution biomass maps, harmonized and upscaled to 14 477 1-km AGB estimates. Our data fusion approach uses bias removal and weighted linear averaging that incorporates and spatializes the biomass patterns indicated by the reference data. The method was applied independently in areas (strata) with homogeneous error patterns of the input (Saatchi and Baccini) maps, which were estimated from the reference data and additional covariates. Based on the fused map, we estimated AGB stock for the tropics (23.4 N-23.4 S) of 375 Pg dry mass, 9-18% lower than the Saatchi and Baccini estimates. The fused map also showed differing spatial patterns of AGB over large areas, with higher AGB density in the dense forest areas in the Congo basin, Eastern Amazon and South-East Asia, and lower values in Central America and in most dry vegetation areas of Africa than either of the input maps. The validation exercise, based on 2118 estimates from the reference dataset not used in the fusion process, showed that the fused map had a RMSE 15-21% lower than that of the input maps and, most importantly, nearly unbiased estimates (mean bias 5 Mg dry mass ha(-1) vs. 21 and 28 Mg ha(-1) for the input maps). The fusion method can be applied at any scale including the policy-relevant national level, where it can provide improved biomass estimates by integrating existing regional biomass maps as input maps and additional, country-specific reference datasets.

Factors influencing social and health outcomes after motor vehicle crash injury: an inception cohort study protocol.

BACKGROUND: There is growing evidence that health and social outcomes following motor vehicle crash injury are related to cognitive and emotional responses of the injured individual, as well as relationships between the injured individual and the compensation systems with which they interact. As most of this evidence comes from other states in Australia or overseas, investigation is therefore warranted to identify the key determinants of health and social outcomes following injury in the context of the New South Wales motor accident insurance scheme. METHODS/DESIGN: In this inception cohort study, 2400 participants, aged 17 years or more, injured in a motor vehicle crash in New South Wales will be identified though hospital emergency departments, general and physiotherapy practitioners, police records and a government insurance regulator database. Participants will be initially contacted through mail. Baseline interviews will be conducted by telephone within 28 days of the injury and participants will be followed up with interviews at 6, 12 and 24 months post-injury. Health insurance and pharmaceutical prescription data will also be collected. DISCUSSION: The study results will report short and long term health and social outcomes in the study sample. Identification of factors associated with health and social outcomes following injury, including related compensation factors will provide evidence for improved service delivery, post-injury management, and inform policy development and reforms. TRIAL REGISTRATION: Australia New Zealand Clinical trial registry identification number--ACTRN12613000889752. Available at: ANZCTR Registered FISH Study.

A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce?

BACKGROUND: This debate discusses the potential merits of a New Graduate Nurse Transition to Primary Health Care Program as an untested but potential nursing workforce development and sustainability strategy. Increasingly in Australia, health policy is focusing on the role of general practice and multidisciplinary teams in meeting the service needs of ageing populations in the community. Primary health care nurses who work in general practice are integral members of the multidisciplinary team - but this workforce is ageing and predicted to face increasing shortages in the future. At the same time, Australia is currently experiencing a surplus of and a corresponding lack of employment opportunities for new graduate nurses. This situation is likely to compound workforce shortages in the future. A national nursing workforce plan that addresses supply and demand issues of primary health care nurses is required. Innovative solutions are required to support and retain the current primary health care nursing workforce, whilst building a skilled and sustainable workforce for the future. DISCUSSION: This debate article discusses the primary health care nursing workforce dilemma currently facing policy makers in Australia and presents an argument for the potential value of a New Graduate Transition to Primary Health Care Program as a workforce development and sustainability strategy. An exploration of factors that may contribute or hinder transition program for new graduates in primary health care implementation is considered. SUMMARY: A graduate transition program to primary health care may play an important role in addressing primary health care workforce shortages in the future. There are, however, a number of factors that need to be simultaneously addressed if a skilled and sustainable workforce for the future is to be realised. The development of a transition program to primary health care should be based on a number of core principles and be subjected to both a summative and cost-effectiveness evaluation involving all key stakeholders.

E-Health readiness in outback communities: an exploratory study.

INTRODUCTION: E-health has been a recurrent topic in health reform, yet its implementation, ultimate role and feasibility are yet to be clearly defined. Organisations such as the Royal Flying Doctor Service South East Section (RFDS SE) are in a position to utilise technology to enhance the effectiveness of existing clinical services for remote communities. The study aim was to explore the readiness of the remote population of far-west New South Wales, Australia, and RFDS SE as a monopoly service provider to take up e-health innovations. METHODS: A convenience sample of patients sequentially attending 15 remote fly-in clinics conducted by RFDS SE medical officers were invited to participate in a semi-structured telephone survey using an established survey tool to gather quantitative and qualitative data. RFDS SE health staff and managers were also surveyed. RESULTS: The overall core-readiness to embrace new e-health technologies was at a moderate level; barriers were mainly technical competence and technology availability. Enablers were willingness to learn and engage. The majority of patients did not feel isolated and had their health needs met; albeit there was interest in change if this improved outcomes. Video consultations for mental health and access to specialists were particularly welcome, although responses also indicated concern that video links might replace existing face-to-face services. Health staff saw the need for new technology to assist in healthcare provision but technology availability and support were flagged as key points. Organisational views as elicited from managers identified internal needs for workplace readiness to assist with adoption of new technology. CONCLUSIONS: Patients, healthcare providers and RFDS SE as an organisation are interested in engaging in e-health to improve the level of healthcare delivery. There are challenges around the technical capacity and the structural and organisational support for an e-health venture in an outback setting. Specific patient, healthcare provider and organisational needs have been identified and allow for the development of a tailor-made implementation strategy particularly to overcome technical challenges.

Tailoring communication practices to support effective delivery of telehealth in general practice.

BACKGROUND: The unprecedented increase in telehealth use due to COVID-19 has changed general practitioners' (GP) and patients' engagement in healthcare. There is limited specific advice for effective communication when using telehealth. Examining telehealth use in practice in conjunction with perspectives on telehealth as they relate to communication allows opportunities to produce evidence-based guidance for optimal use of telehealth, while also offering practitioners the opportunity to reflect on elements of their communicative practice common to both styles of consultation. The objective of this research was to develop evidence-based resources to support effective, person-centred communication when GPs and patients use telehealth. This included examination of interactional practices of recorded telehealth consultations, exploration of GP and patient perspectives relating to telehealth, and identifying priorities for guidance informed by these analyses as well as participant co-design. METHODS: This study involved recording telehealth consultations (n = 42), conducting patient surveys (n = 153), and interviewing patients (n = 9) and GPs (n = 15). These were examined using interaction analytic methods, quantitative analysis, and thematic analyses, to create a robust, integrated picture of telehealth practice and perspectives. The process of research translation involved a co-design approach, engaging with providers, patients, and policy makers to facilitate development of evidence-based principles that focus on supporting effective communication when using telehealth. RESULTS: Three key themes relating to communication in telehealth were identified across the different analyses. These were relationship building, conversational flow, and safety netting. The draft best practice principles drawn from these themes were modified based on co-design feedback into five Best Practice Principles for Communication between GPs and Patients using Telehealth. CONCLUSIONS: Effective communication is supported through relationship building and attention to conversational flow in telehealth consultations, which in turn allows for safety netting to occur. In telehealth, GPs and patients recognise that not being co-present changes the consultation and use both intuitive and strategic interactional adjustments to support their exchange. The mixed-method examination of experiences through both a detailed analysis of telehealth consultations in practice and comparative exploration of GP and patient perspectives enabled the identification of principles that can support effective communication when using telehealth. Co-design helped ensure these principles are ready for implementation into practice.

Experiences and perspectives of colorectal cancer survivors and general practitioners on the delivery of survivorship care in general practice: a mixed methods study.

BACKGROUND: Many colorectal cancer (CRC) survivors experience ongoing sequelae from their cancer treatment. Limited evidence exists regarding how CRC survivors and general practitioners (GPs) manage these sequelae in the community. This study aimed to explore the experiences and perspectives of CRC survivors and GPs on current approaches to monitoring and managing sequelae of CRC treatment. METHODS: We conducted a mixed-methods study using cross-sectional national surveys and qualitative interviews with CRC survivors and GPs to explore: (1) treatment sequelae experienced by CRC survivors, (2) how these were monitored and managed by general practitioners, and (3) suggestions to improve ongoing management of the treatment sequelae. Survey responses were reported descriptively. Qualitative data were thematically analysed using an interpretive descriptive approach. RESULTS: Seventy participants completed surveys: 51 CRC survivors and 19 GPs, and four interviews were conducted with GPs. CRC survivors experienced a range of treatment sequelae, but often did not discuss these with their GPs (experienced vs discussed: 86% vs 47% for fatigue/lack of energy, 78% vs 27% for psychological/emotional concern, 63% vs 22% for impaired sleep, 69% vs 29% for weight loss/gain, 59% vs 16% for sexual and intimacy concerns). GPs reported inadequate information transfer from cancer services and workload as major barriers to optimal care. CONCLUSIONS: System-level changes that facilitate adequate information transfer from cancer services to GPs upon CRC treatment completion, as well as addressing time constraint issues essential for comprehensive monitoring and management of CRC treatment sequelae, could enhance the care of CRC survivors in the community setting.

Place attachment and perception of climate change as a threat in rural and urban areas.

Climate change is a global threat to ecosystems and the people that depend on them. However, the perceived threat of climate change may vary spatially. Previous research suggests that inhabitants in rural areas show higher levels of place attachment (associating meaning with a specific place) than urbanites, possibly because rural people depend more directly on their local environment. This can shape perceptions and behaviours, such as enhanced willingness to engage in landscape preservation. Here we ask if it also makes rural people perceive climate change as a greater threat, using a representative sample of 1,071 survey respondents from across the United Kingdom (UK) to provide first-order insights. We found that, whilst indicators of place attachment were indeed more frequent in rural areas, the perceived threat of climate change in the most rural locations was lower. We discuss possible explanations for this pattern (including lower levels of awareness of the anthropogenic causes of climate change, lessened first-hand experiences of climate change impacts due to higher levels of regulating ecosystem services, and higher levels of resilience in rural areas related to a closer relationship with nature), and call for further research to investigate this.

Pattern of mental health attendances at a metropolitan university general practice clinic in Sydney before and during the COVID-19 pandemic.

BACKGROUND AND OBJECTIVES: The aim of this study was to describe the pattern of mental health attendances in a university-based general practice clinic during phases of the COVID-19 pandemic. The COVID-19 pandemic has created social and medical disruptions to the Australian community. There is a literature gap pertaining to the ongoing trends that extend beyond the initial 'first wave' of the pandemic in the context of the Australian landscape. METHOD: Retrospective data were obtained from 435 adults attending a community university-based general practice in Sydney, Australia, during four time periods: T1, before the COVID-19 pandemic (1 February - 7 March 2019); T2, during the first COVID-19 lockdown (31 March - 4 May 2020); T3, during the second COVID-19 lockdown (20 August - 23 September 2021); and T4, after the end of the COVID-19 lockdowns (1 February - 7 March 2022). Attendances were identified as mental health Medicare Benefits Schedule codes for face-to-face, televideo and telephone consultations. Patterns of attendances were evaluated using frequency analysis. RESULTS: There was a decline in mental health attendances compared to all attendances at the general practice from T1 (7.5%) to T2 (4.8%). During T4, mental health attendances returned to 7.1% of all consultations at the general practice. Face-to-face attendances decreased by 50% in T2 relative to T1, and this trend was maintained in T3 and T4, whereas the utilisation of telehealth approached that of face-to-face by T4. DISCUSSION: Post-pandemic policies that support the use of telehealth in general practice may help improve mental healthcare delivery and outcomes.

Experiences of colorectal cancer survivors in returning to primary coordinated healthcare following treatment.

BACKGROUND: Advances in screening and treatments for colorectal cancer (CRC) have improved survival rates, leading to a large population of CRC survivors. Treatment for CRC can cause long-term side-effects and functioning impairments. General practitioners (GPs) have a role in meeting survivorship care needs of this group of survivors. We explored CRC survivors' experiences of managing the consequences of treatment in the community and their perspective on the GP's role in post-treatment care. METHODS: This was a qualitative study using an interpretive descriptive approach. Adult participants no longer actively receiving treatment for CRC were asked about: side-effects post-treatment; experiences of GP-coordinated care; perceived care gaps; and perceived GP role in post-treatment care. Thematic analysis was used for data analysis. RESULTS: A total of 19 interviews were conducted. Participants experienced side-effects that significantly impacted their lives; many they felt ill-prepared for. Disappointment and frustration was expressed with the healthcare system when expectations about preparation for post-treatment effects were not met. The GP was considered vital in survivorship care. Participants' unmet needs led to self-management, self-directed information seeking and sourcing referral options, leaving them feeling like their own care coordinator. Disparities in post-treatment care between metropolitan and rural participants were observed. CONCLUSION: There is a need for improved discharge preparation and information for GPs, and earlier recognition of concerns following CRC treatment to ensure timely management and access to services in the community, supported by system-level initiatives and appropriate interventions.

The journey to a learning health system in primary care: a qualitative case study utilising an embedded research approach.

BACKGROUND: Healthcare systems may be resilient and adaptive, but they are not fit for purpose in their current state. Increasing threats to health system sustainability have underscored the need to move towards a learning health system in which research and data are used routinely in clinical practice to facilitate system improvement. This study aimed to establish which elements of the learning health system were being realised within a university-based general practice and determine acceptability from staff to embrace further the transition towards a learning health system. METHODS: Semi-structured interviews were conducted with practice staff, including clinical and administrative staff, to determine the current state of the learning health system in the practice. An embedded researcher was placed within the general practice on a part-time basis to investigate the learning health system model. Interviews were transcribed and thematically analysed based on the National Academy of Medicine's framework of learning health systems. RESULTS: In total, 32 (91%) practice staff were interviewed, comprising general practitioners (n = 15), nurses (n = 3), administrative staff (n = 13), and a psychologist (n = 1). Participants indicated that the practice was operating with several characteristics of a learning health system (e.g., emphasising science and informatics; focusing on patient-clinician partnerships; applying incentives; supporting a continuous learning culture; and establishing structures and governance for learning). These measures were supported by the university-based setting, and resultant culture of learning. Nevertheless, there were areas of the practice where the learning health system could be strengthened, specifically relating to the use of patient data and informatics. Staff generally expressed willingness to engage with the process of strengthening the learning health system within their practice. CONCLUSION: Although the idea of a learning health system has been gaining traction in recent years, there are comparatively few empirical studies presented in the literature. This research presents a case study of a general practice that is operating as a learning health system and highlights the utility of using the learning health system framework.

Model ensembles of ecosystem services fill global certainty and capacity gaps.

Sustaining ecosystem services (ES) critical to human well-being is hindered by many practitioners lacking access to ES models ("the capacity gap") or knowledge of the accuracy of available models ("the certainty gap"), especially in the world's poorer regions. We developed ensembles of multiple models at an unprecedented global scale for five ES of high policy relevance. Ensembles were 2 to 14% more accurate than individual models. Ensemble accuracy was not correlated with proxies for research capacity, indicating that accuracy is distributed equitably across the globe and that countries less able to research ES suffer no accuracy penalty. By making these ES ensembles and associated accuracy estimates freely available, we provide globally consistent ES information that can support policy and decision-making in regions with low data availability or low capacity for implementing complex ES models. Thus, we hope to reduce the capacity and certainty gaps impeding local- to global-scale movement toward ES sustainability.

Experiences of telehealth in general practice in Australia: research protocol for a mixed-methods study.

BACKGROUND: Owing to the COVID-19 pandemic, the use of telehealth has expanded rapidly. However, little is known about the impact of delivering care through telehealth on communication between clinicians and patients. At an interactional level, the ways in which clinicians establish rapport and connection with their patients in telehealth consultations is not well understood. AIM: This study will explore interactional practices of GPs and patients in telehealth consultations to develop evidence-based resources to improve communication. DESIGN & SETTING: The study will be conducted within the Australian general practice setting. METHOD: Conversation analysis and sociolinguistic discourse analysis of recorded telehealth consultations will provide direct evidence of specific elements contributing to successful and less successful instances of telehealth communication. This analysis will be complemented by co-design techniques such as qualitative and reflective interviews, and collaborative workshops with telehealth users including both GPs and patients. CONCLUSION: Effective communication is critical for telehealth consultations and is central to achieving optimal clinical outcomes and patient satisfaction. Evidence-based guidelines encompassing effective telehealth communication strategies will be co-developed with end-users in this study.

Development of an individualised primary care program for acute low back pain using a hybrid co-design framework.

BACKGROUND: Low back pain is the leading worldwide cause of years lost to disability and the problem is worsening. This paper describes and demonstrates the scholarly development and contextual refinement of a primary care program for acute low back pain in Sydney, Australia. METHODS: Hybrid theoretical frameworks were applied, and co-design was used to contextualise the program to the local healthcare setting. RESULTS: The program was developed in four stages. In stage 1, the scientific evidence about management of acute low back pain in primary care was examined. In stage 2, stakeholders (patients and clinicians) were consulted in nationwide surveys. Data from stages 1 and 2 were used to design an initial version of the program, called My Back My Plan. Stage 3 involved the contextual refinement of the program to the local setting, MQ Health Primary Care. This was achieved by co-design with primary care clinicians and patients who had sought care for low back pain at MQ Health Primary Care clinics. In stage 4, a panel of Australian experts on clinical care for low back pain reviewed the contextualised version of My Back My Plan and final amendments were made. CONCLUSION: My Back My Plan has been developed using an innovative scholarly approach to intervention development.