Australian general practitioners' perspectives on integrating specialist diabetes care with primary care: qualitative study.

BACKGROUND: Improving the coordination and integration of health services is recognised nationally and internationally as a key strategy for improving the quality of diabetes care. The Australian Diabetes Alliance Program (DAP) is an integrated care model implemented in the Hunter New England Local Health District (HNELHD), New South Wales (NSW), in which endocrinologists and diabetes educators collaborate with primary care teams via case-conferencing, practice performance review, and education sessions. The objective of this study was to report on general practitioners' (GPs) perspectives on DAP and whether the program impacts on their skills, knowledge, and approach in delivering care to adult patients with type 2 diabetes. METHODS: Four primary care practices with high rates of monitoring haemoglobin A1c (HbA1c) levels (> 90% of patients annually) and five practices with low rates of monitoring HbA1c levels (< 80% of patients annually) from HNELHD, NSW provided the sampling frame. A total of nine GPs were interviewed. The transcripts from the interviews were reviewed and analysed to identify emergent patterns and themes. RESULTS: Overall, GPs were supportive of DAP. They considered that DAP resulted in significant changes in their knowledge, skills, and approach and improved the quality of diabetes care. Taking a more holistic approach to care, including assessing patients with diabetes for co-morbidities and risk factors that may impact on their future health was also noted. DAP was noted to increase the confidence levels of GPs, which enabled active involvement in the provision of diabetes care rather than referring patients for tertiary specialist care. However, some indicated the program could be time consuming and greater flexibility was needed. CONCLUSIONS: GPs reported DAP to benefit their knowledge, skills and approach for managing diabetes. Future research will need to investigate how to improve the intensity and flexibility of the program based on the workload of GPs to ensure long-term acceptability of the program.

Residential Medication Management Reviews and continuous polypharmacy among older Australian women.

Background Polypharmacy is an important consideration for the provision of Residential Medication Management Reviews (RMMRs) among older women given their enhanced risk of medication-related problems and admission to residential aged care (RAC). Objectives To determine the prevalence of the use of RMMRs among older women in RAC, and the association between RMMRs and polypharmacy, medications, and costs. Setting Older Australian women aged 79-84 years in 2005 who had at least one Medicare Benefits Schedule and Pharmaceutical Benefits Scheme record, received a service in aged care, and consented to data linkage. Methods Generalised estimating equations were used to determine the association between polypharmacy and RMMRs, while adjusting for confounding variables. Main outcome measures Prevalence of the use of RMMRs among older women in RAC, association between RMMRs and polypharmacy, medications, and costs. Results Most participants did not have continuous polypharmacy and did not receive RMMRs from 2005 [451 (67.4%)] until 2017 [666 (66.6%)]. Participants with continuous polypharmacy were 17% more likely to receive a RMMR (risk ratio 1.17; 95% confidence interval 1.11, 1.25). Participants in their final year of life and residing in outer regional/remote/very remote Australia were less likely to receive RMMRs. Out-of-pocket medication costs increased over time, and alendronate and aspirin were common contributors to polypharmacy among participants who received RMMRs. Conclusion Polypharmacy was associated with receiving RMMRs and around two-thirds of women who are entitled to a RMMR never received one. There is potential to improve the use of medicines by increasing awareness of the service among eligible individuals, their carers and health care professionals.

The Joint Effects of Diet and Dietary Supplements in Relation to Obesity and Cardiovascular Disease over a 10-Year Follow-Up: A Longitudinal Study of 69,990 Participants in Australia.

It is unknown whether a healthy diet or unhealthy diet combined with specific supplements may jointly contribute to incidence of obesity and cardiovascular disease (CVD). We included 69,990 participants from the 45 and Up Study who completed both baseline (2006-2009) and follow-up (2012-2015) surveys. We found that compared to participants with a long-term healthy diet and no supplement consumption, those with a long-term healthy diet combined with multivitamins and minerals (MVM) or fish oil consumption were associated with a lower incidence of CVD (p < 0.001); whilst those with an unhealthy diet and no MVM or fish oil consumption were associated with a higher risk of obesity (p < 0.05). Compared to participants with a long-term healthy diet and no calcium consumption, the combination of a long-term healthy diet and calcium consumption was linked to a lower risk of CVD (IRR = 0.87, 95% CI: 0.78; 0.96). In conclusion, a long-term healthy diet combined with MVM or fish oil was associated with a lower incidence of CVD. Participants who maintained a healthy diet and used calcium supplements were associated with a lower incidence of obesity. However, these associations were not found among those with an unhealthy diet, despite taking similar supplements.

"They were all together discussing the best options for me": Integrating specialist diabetes care with primary care in Australia.

Over one-third of diabetes-related encounters with healthcare providers in Australia fail to meet clinical guidelines. Evidence is mounting that care provision within an integrated framework may facilitate greater adherence to clinical guidelines and improved outcomes for patients. The Diabetes Alliance Program was implemented across a large healthcare district to enhance diabetes care capacity at the primary care level through intensive case-conferencing involving the primary care team, patients and visiting specialist team, whole practice performance review and regular diabetes education for practitioners. Here, we provide an in-depth patient assessment of the case-conferencing process and impact on diabetes management. Two practices with high pre-intervention HbA1c monitoring and three practices with low HbA1c monitoring provided the sampling frame. Patients were selected according to their score on the Patient Activation MeasureTM to achieve maximum variation, with up to two patients with high scores and three with low scores, selected from each practice. Patients were sampled until data saturation was achieved and then subjected to thematic content analysis (n = 19). Patients mostly described the model of care as a positive experience, reporting a boost in confidence in diabetes self-management (particularly around nutrition). The program was also seen to be helpful in providing an opportunity to refocus when "life gets in the way". Other valued aspects of the program included the holistic approach to healthcare, reduced travel time, familiarity in environment and clinical care, top-down knowledge transfer as well as mutual learning by the patient and their primary care team. Despite this, difficulties in coping with diabetes and adherence to treatment recommendations remained for a minority of patients. Integrating specialist teams within primary care has the ability to provide efficient healthcare delivery, better patient experience and health outcomes. Investment in such approaches will be critical to navigating healthcare provision in order to meet the demands of an ageing population.

Use of medication reviews among older women with dementia, 2003-2015: A longitudinal cohort study.

OBJECTIVE: To identify factors associated with incidence of medication reviews (MRs), particularly in women with dementia and in residential aged care (RAC). METHODS: Data from 10 359 women in the 1921-1926 cohort of the Australian Longitudinal Study on Women's Health were linked to Medicare Benefits Schedule data to identify MRs for each year from 2003 to 2015. RESULTS: Incidence of MR increased from 2003 to 2013 (age 87-92 years) when 37.1% of women with dementia had a MR compared to 19.8% of women without dementia. Adjusting for time and other factors, the odds of having a MR were higher for women with dementia (AOR = 1.18, 95% CI: 1.06-1.32) and women in RAC (AOR = 3.61, 95% CI: 3.28-3.98). CONCLUSIONS: Although higher in women with dementia and those in RAC, utilisation of MR was modest. System-level interventions may be required to ensure the use and benefits of MRs.

The Relationship Between Spinal Pain and Comorbidity: A Cross-sectional Analysis of 579 Community-Dwelling, Older Australian Women.

OBJECTIVES: The aims of this study were to (1) report the prevalence and explore the influence of spinal pain on quality of life and (2) assess the relationship between spinal pain and the type and number of comorbidities. METHODS: This cross-sectional study comprised 579 community-dwelling, older Australian women. Women had "spinal pain" if they marked "yes" to neck pain, upper back pain, mid-back pain, and/or lower back pain. Descriptive statistics and binary logistic regression were performed to report the prevalence and explore the relationship between spinal pain and the type and number of comorbidities. RESULTS: A majority of women (55.8%) who returned surveys had spinal pain. Women with spinal pain had significantly lower physical and mental quality of life scores than women without spinal pain (Medical Outcomes Study: 36 Item Short Form Survey [SF-36] physical component summary: 40.1 ± 11.1 vs 49.0 ± 9.0, and SF-36 mental component summary: 50.0 ± 10.5 vs 53.9 ± 8.2, respectively). Having spinal pain was significantly associated with overweight and obesity (odds ratio 1.98 [95% confidence interval 1.3-2.96] and 2.12 [1.37-3.28]), diabetes (1.93 [1.01-3.67]), pulmonary comorbidity (1.66 [1.04-2.65]), and cardiovascular comorbidity (1.57 [1.07-2.28]). More than half of the women with spinal pain reported 2 or more comorbidities, with comorbidities significantly more common among women with spinal pain than among women without spinal pain. The odds of having spinal pain increased with an increasing number of comorbidities (2 comorbidities: 2.44 [1.47-4.04], 3 comorbidities: 3.07 [1.66-5.67], 4 comorbidities: 5.05 [1.64-15.54]). CONCLUSIONS: Spinal pain is common in community-dwelling, older Australian women and is associated with greater disability and poorer quality of life. Diabetes, cardiovascular disease, pulmonary disease, and obesity appear to have a relationship with spinal pain. There was an incremental increase in the risk of spinal pain associated with increasing comorbidity count.

Uptake, prevalence and predictors of first-time use for the 75+ Health Assessment Scheme.

In 1999, the Australian Federal Government introduced Medicare items for Health Assessments for people aged 75 years and older (75+ health assessments). This research examined uptake of these assessments and identified predictors of use by women from the Australian Longitudinal Study on Women's Health (ALSWH). Assessments were identified for each year from 1999 to 2013 using linked Medicare data. Time to first assessment was examined, as well as social and health factors associated with having an assessment. From 1999 to 2013, 61.8% of women had at least one assessment. Almost one-third had an assessment within 2 years of their introduction, 25% of women died before having an assessment and 13% survived but did not have an assessment. Factors associated with assessment included being widowed, private health insurance, marital status, education, having arthritis and urinary incontinence, and less difficulty managing on income. Many women never received an assessment, and many only received one. Promotion of the 75+ health assessments is necessary among older women to increase uptake.

Dietary pattern, serum magnesium, ferritin, C-reactive protein and anaemia among older people.

BACKGROUND & AIMS: Epidemiological data of dietary patterns and anaemia among older Chinese remains extremely scarce. We examined the association between dietary patterns and anaemia in older Chinese, and to assess whether biomarkers of serum magnesium, C-reactive protein (CRP) and serum ferritin can mediate these associations. METHODS: We analysed the 2009 China Health and Nutrition Survey data (2401 individuals aged ≥60 years for whom both dietary and biomarker data are available). Dietary data was obtained using 24 h-recall over three consecutive days. Fasting blood samples and anthropometry measurement were also collected. Factor analysis was used to identify dietary patterns. Factor scores representing dietary patterns were used in Poisson regression models to explore the association between each dietary pattern and anaemia. RESULTS: Of the 2401 participants, 18.9% had anaemia, 1.9% had anaemia related to inflammation (AI), and 1.3% had iron-deficiency anaemia (IDA). A traditional dietary pattern (high intake of rice, pork and vegetables) was positively associated with anaemia; a modern dietary pattern (high intake of fruit and fast food) was inversely associated with anaemia. Progressively lower magnesium and BMI levels were associated with increasing traditional dietary quartiles; while a progressively higher magnesium and BMI levels were associated with increasing modern dietary quartiles (p < 0.001). There were no significant differences (p > 0.05) in CRP and serum ferritin across quartiles for either dietary pattern. In the fully adjusted model, the prevalence ratio (PR) of anaemia, comparing the fourth quartile to the first quartile, was 1.75 (95% CI: 1.33; 2.29) for a traditional dietary pattern, and 0.89 (95% CI: 0.68; 1.16) for a modern dietary pattern. The association between dietary patterns and anaemia is mediated by serum magnesium. CONCLUSION: Traditional dietary pattern is associated with a higher prevalence of anaemia among older Chinese. Future studies need to examine whether correcting micronutrient deficiency (e.g. magnesium) by promoting overall healthy diet, rather than iron supplementation, is a suitable strategy for anaemia prevention in older Chinese people.

Exploring the implementation of poslansia,†Indonesia's community-based health programme for older people.

AIM: To explore the implementation of poslansia, a community-based integrated health service implemented across Indonesia to improve the health status of older people through health promotion and disease prevention. METHODS: Data analysis of 307 poslansia surveyed in the 4th wave of Indonesia Family Life Survey (IFLS-4). We examined the services provided in the programme, resources and perceived problems. RESULTS: The services provided by poslansia focused mostly on risk factor screening and treatment for minor illness, and less on health promotion activities. Lack of support from community health centres, no permanent place for holding poslansia and lack of participant interest in joining the programme were associated with fewer services provided in the programme (P < 0.05). CONCLUSION: The findings indicate existing support from the community, community health centres and related institutions for poslansia is not adequate for optimal service function. Health awareness among the older population should also be increased for programme sustainability.

Effects of dietary interventions on pregnancy outcomes: a systematic review and meta-analysis.

Dietary intake during pregnancy influences maternal health. Poor dietary practices during pregnancy have been linked to maternal complications. The objective was to determine the effect of dietary intervention before or during pregnancy on pregnancy outcomes. A systematic review was conducted without date restrictions. Randomised controlled trials (RCTs) evaluating whole diet or dietary components and pregnancy outcomes were included. Two authors independently identified papers for inclusion and assessed methodological quality. Meta-analysis was conducted separately for each outcome using random effects models. Results were reported by type of dietary intervention: (1) counselling; (2) food and fortified food products; or (3) combination (counseling + food); and collectively for all dietary interventions. Results were further grouped by trimester when the intervention commenced, nutrient of interest, country income and body mass index. Of 2326 screened abstracts, a total of 28 RCTs were included in this review. Dietary counselling during pregnancy was effective in reducing systolic [standardised mean difference (SMD) -0.26, 95% confidence interval (CI) -0.45 to -0.07; P < 0.001] and diastolic blood pressure (SMD -0.57, 95% CI -0.75 to -0.38; P < 0.001). Macronutrient dietary interventions were effective in reducing the incidence of preterm delivery (SMD -0.19, 95% CI -0.34 to -0.04; P = 0.01). No effects were seen for other outcomes. Dietary interventions showed some small, but significant differences in pregnancy outcomes including a reduction in the incidence of preterm birth. Further high-quality RCTs, investigating micronutrient provision from food, and combination dietary intervention, are required to identify maternal diet intakes that optimise pregnancy outcomes.

A case-control study of risk factors for fetal and early neonatal deaths in a tertiary hospital in Kenya.

BACKGROUND: It is important to understand the risk factors for fetal and neonatal mortality which is a major contributor to high under five deaths globally. Fetal and neonatal mortality is a sensitive indicator of maternal health in society. This study aimed to examine the risk factors for fetal and early neonatal mortality at the Moi Teaching and Referral Hospital in Kenya. METHODS: This was a case-control study. Cases were fetal and early neonatal deaths (n = 200). The controls were infants born alive immediately preceding and following the cases (n = 400). Bivariate comparisons and multiple logistic regression analyses were undertaken. RESULTS: The odds of having 0-1 antenatal visits relative to 2-3 visits were higher for cases than controls (Adjusted Odds Ratio (AOR) = 4.5; 95% CI: 1.2-16.7; p = 0.03)). There were lower odds among cases of having a doctor rather than a midwife as a birth attendant (AOR = 0.2; 95% CI: 0.1-0.6; p < 0.01). The odds of mothers having Premature Rupture of Membranes (AOR = 4.1; 95% CI: 1.4-12.1; p = 0.01), haemorrhage (AOR = 4.8; 95% CI: 1.1-21.9; p = 0.04) and dystocia (AOR = 3.6; 95% CI: 1.2-10.9; p = 0.02) were higher for the cases compared with the controls. The odds of gestational age less than 37 weeks (AOR = 7.0; 95% CI 2.4-20.4) and above 42 weeks (AOR = 16.2; 95% CI 2.8-92.3) compared to 37-42 weeks, were higher for cases relative to controls (p < 0.01). Cases had higher odds of being born with congenital malformations (AOR = 6.3; 95% CI: 1.2-31.6; p = 0.04) and with Apgar scores of below six at five minutes (AOR = 26.4; 95% CI: 6.1-113.8; p < 0.001). CONCLUSION: Interventions that focus on educating mothers on antenatal attendance, screening, monitoring and management of maternal conditions during the antenatal period should be strengthened. Doctor attendance at each birth and for emergency admissions is important to ensure early neonatal survival and avert potential risk factors for mortality.

Mental health service use: is there a difference between rural and non-rural women in service uptake?

This study examines differences in uptake of the Medicare items rolled out in 2006 under the 'Better Access Scheme' (BAS) between rural and non-rural Australian women. It compares differences in women's uptake of the BAS services by area of residence (ARIA+) across time using the Australian Longitudinal Study of Women's Health (ALSWH) survey data linked to Medicare data. Women aged 28-33 years at the time the BAS was introduced that responded to the self-reported question on depression/anxiety and consented to linkage of their survey data with Medicare data (n=4,316). Participants were grouped by ARIA+ according to BAS use, diagnoses of anxiety/depression but no BAS use and other eligible women. Across all areas, women born 1973-1978 with a self-reported diagnosis of depression/anxiety or having treatment under the BAS had a significantly lower mean mental health score compared to other women. Significantly more women living in non-rural areas had used at least one service provided under the BAS initiative compared to women in outer regional, inner regional or remotes areas (21% versus 18% versus 13% versus 7%, respectively), and across all areas, 12% of women reported having a diagnosis of depression/anxiety but not been treated under the BAS. While there is a gradual uptake of the new BAS services, a large percentage of women who have a diagnosis of depression/anxiety have not been treated under the BAS. The data suggest that women in urban areas have been better able to take up the services compared to non-urban women.

Is dietary zinc protective for type 2 diabetes? Results from the Australian longitudinal study on women's health.

BACKGROUND: Animal studies have shown that zinc intake has protective effects against type 2 diabetes, but few studies have been conducted to examine this relationship in humans. The aim of this study is to investigate if dietary zinc is associated with risk of type 2 diabetes in a longitudinal study of mid-age Australian women. METHODS: Data were collected from a cohort of women aged 45-50 years at baseline, participating in the Australian Longitudinal Study on Women's Health. A validated food frequency questionnaire was used to assess dietary intake and other nutrients. Predictors of 6-year incidence of type 2 diabetes were examined using multivariable logistic regression. RESULTS: From 8921 participants, 333 incident cases of type 2 diabetes were identified over 6 years of follow-up. After adjustment for dietary and non-dietary factors, the highest quintile dietary zinc intake had almost half the odds of developing type 2 diabetes (OR = 0.50, 95% C.I. 0.32-0.77) compared with the lowest quintile. Similar findings were observed for the zinc/iron ratio; the highest quintile had half the odds of developing type 2 diabetes (OR = 0.50, 95% C.I 0.30-0.83) after multivariable adjustment of covariates. CONCLUSIONS: Higher total dietary zinc intake and high zinc/iron ratio are associated with lower risk of type 2 diabetes in women. This finding is a positive step towards further research to determine if zinc supplementation may reduce the risk of developing type 2 diabetes.

A cluster randomised controlled trial to prevent injury due to falls in a residential aged care population.

OBJECTIVE: To test the effectiveness of using a full-time project nurse to assist residential aged care facilities in using evidence-based approaches to falls injury prevention. DESIGN, SETTING AND PARTICIPANTS: Cluster randomised controlled trial involving 5391 residents in 88 aged care facilities in the Hunter and Lower Mid North Coast areas of New South Wales. Residents were followed for 545 days or until death or discharge. Data were collected from July 2005 to June 2007. INTERVENTION: Employment of a project nurse to encourage best-practice falls injury prevention strategies during the 17-month intervention period. MAIN OUTCOME MEASURES: Monthly data about falls, falls injury and falls injury prevention programs; audit of hospitalisation for fractured neck of femur. RESULTS: Despite significant increases in the provision of hip protectors and use of vitamin D supplementation in both intervention and control facilities, there was no difference in the number of falls or falls injuries between the intervention and control groups, nor a reduction in falls overall. There was also no difference between the 7-month pre-intervention period and the intervention period in the number of falls or falls injuries. Factors related to residents having an increased risk of falls with fractured neck of femur included being ambulant, having dementia, increasing age, and having a high falls risk assessment score. CONCLUSION: It is difficult to change falls risk among high-risk populations, including people with dementia. The use of important strategies such as hip protectors and vitamin D and calcium supplementation increased during the study, probably with contamination of control facilities. Longer follow-up may be required to measure the impact on falls outcomes of the strategy of using a facilitating nurse. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12605000540617.

Prevalence of self-reported risk factors for medication misadventure among older people in general practice.

OBJECTIVE: To describe the prevalence of risk factors for medication misadventures among older people in general practice. DESIGN: Descriptive cross-sectional analysis. SETTING: General practices, New South Wales, Australia. PARTICIPANTS: Twenty general practitioners in 16 practices recruited 849 practice attendees aged 65 years and over. OUTCOME MEASURE: Risk factors for medication misadventures. RESULTS: Almost all participants (95%) had used at least one medication for more than 6 months. More than half of the participants had more than one doctor involved in their care (59%), had three or more health conditions (57%), or used five or more medicines (54%). With regard to potential adverse drug reactions, in the last month 39% of participants experienced difficulties sleeping, one-third felt drowsy or dizzy (34%), and about a quarter had a skin rash (28%), leaked urine (27%), had stomach problems (22%) or had been constipated (22%). The most common compliance problems were experiencing side effects (14%) and having difficulties opening bottles or packets/applying the medicine (10%). CONCLUSION: Risk factors for medication misadventure remain a substantial problem among older people. A Medication Risk Assessment Form completed by patients can be used as an aid to increase general practitioners' awareness of a variety of problem areas associated with medication use in a compact way, and could be used as part of a system for medication review to determine whether actions are required to improve quality use of medicines.