Knowledge, attitudes and beliefs towards management of men with locally advanced prostate cancer following radical prostatectomy: an Australian survey of urologists.

OBJECTIVE: To investigate Australian urologists' knowledge, attitudes and beliefs, and the association of these with treatment preferences relating to guideline-recommended adjuvant radiotherapy for men with adverse pathologic features following radical prostatectomy. SUBJECTS AND METHODS: A nationwide mailed and web-based survey of Australian urologist members of the Urological Society of Australia and New Zealand (USANZ). RESULTS: 157 surveys were included in the analysis (45% response rate). Just over half of respondents (54%) were aware of national clinical practice guidelines for the management of prostate cancer. Urologists' attitudes and beliefs towards the specific recommendation for post-operative adjuvant radiotherapy for men with locally advanced prostate cancer were mixed. Just over half agreed the recommendation is based on a valid interpretation of the underpinning evidence (54.1%, 95% CI [46%, 62.2%]) but less than one third agreed adjuvant radiotherapy will lead to improved patient outcomes (30.2%, 95% CI [22.8%, 37.6%]). Treatment preferences were varied, demonstrating clinical equipoise. A positive attitude towards the clinical practice recommendation was significantly associated with treatment preference for adjuvant radiotherapy (rho = 0.520, P < 0.0001). There was stronger preference for adjuvant radiotherapy in more recently trained urologists (registrars) while preference for watchful waiting was greater in more experienced urologists (consultants) (b = 0.156, P = 0.034; 95% CI [0.048, 1.24]). Urologists' attitudes towards clinical practice guidelines in general were positive. CONCLUSION: There remains clinical equipoise among Australian urologists in relation to adjuvant radiotherapy for men with adverse pathologic features following radical prostatectomy.

The effectiveness of clinical networks in improving quality of care and patient outcomes: a systematic review of quantitative and qualitative studies.

BACKGROUND: Reorganisation of healthcare services into networks of clinical experts is increasing as a strategy to promote the uptake of evidence based practice and to improve patient care. This is reflected in significant financial investment in clinical networks. However, there is still some question as to whether clinical networks are effective vehicles for quality improvement. The aim of this systematic review was to ascertain the effectiveness of clinical networks and identify how successful networks improve quality of care and patient outcomes. METHODS: A systematic search was undertaken in accordance with the PRISMA approach in Medline, Embase, CINAHL and PubMed for relevant papers between 1 January 1996 and 30 September 2014. Established protocols were used separately to examine and assess the evidence from quantitative and qualitative primary studies and then integrate findings. RESULTS: A total of 22 eligible studies (9 quantitative; 13 qualitative) were included. Of the quantitative studies, seven focused on improving quality of care and two focused on improving patient outcomes. Quantitative studies were limited by a lack of rigorous experimental design. The evidence indicates that clinical networks can be effective vehicles for quality improvement in service delivery and patient outcomes across a range of clinical disciplines. However, there was variability in the networks' ability to make meaningful network- or system-wide change in more complex processes such as those requiring intensive professional education or more comprehensive redesign of care pathways. Findings from qualitative studies indicated networks that had a positive impact on quality of care and patients outcomes were those that had adequate resources, credible leadership and efficient management coupled with effective communication strategies and collaborative trusting relationships. CONCLUSIONS: There is evidence that clinical networks can improve the delivery of healthcare though there are few high quality quantitative studies of their effectiveness. Our findings can provide policymakers with some insight into how to successfully plan and implement clinical networks by ensuring strong clinical leadership, an inclusive organisational culture, adequate resourcing and localised decision-making authority.

Development and validation of a survey to measure features of clinical networks.

BACKGROUND: Networks of clinical experts are increasingly being implemented as a strategy to improve health care processes and outcomes and achieve change in the health system. Few are ever formally evaluated and, when this is done, not all networks are equally successful in their efforts. There is a need to formatively assess the strategic and operational management and leadership of networks to identify where functioning could be improved to maximise impact. This paper outlines the development and psychometric evaluation of an Internet survey to measure features of clinical networks and provides descriptive results from a sample of members of 19 diverse clinical networks responsible for evidence-based quality improvement across a large geographical region. METHODS: Instrument development was based on: a review of published and grey literature; a qualitative study of clinical network members; a program logic framework; and consultation with stakeholders. The resulting domain structure was validated for a sample of 592 clinical network members using confirmatory factor analysis. Scale reliability was assessed using Cronbach's alpha. A summary score was calculated for each domain and aggregate level means and ranges are reported. RESULTS: The instrument was shown to have good construct validity across seven domains as demonstrated by a high level of internal consistency, and all Cronbach's α coefficients were equal to or above 0.75. In the survey sample of network members there was strong reported commitment and belief in network-led quality improvement initiatives, which were perceived to have improved quality of care (72.8 %) and patient outcomes (63.2 %). Network managers were perceived to be effective leaders and clinical co-chairs were perceived as champions for change. Perceived external support had the lowest summary score across the seven domains. CONCLUSIONS: This survey, which has good construct validity and internal reliability, provides a valid instrument to use in future research related to clinical networks. The survey will be of use to health service managers to identify strengths and areas where networks can be improved to increase effectiveness and impact on quality of care and patient outcomes. Equally, the survey could be adapted for use in the assessment of other types of networks.

What are the reasons for clinical network success? A qualitative study.

BACKGROUND: Clinical networks have been established to improve patient outcomes and processes of care by implementing a range of innovations and undertaking projects based on the needs of local health services. Given the significant investment in clinical networks internationally, it is important to assess their effectiveness and sustainability. This qualitative study investigated the views of stakeholders on the factors they thought were influential in terms of overall network success. METHOD: Ten participants were interviewed using face-to-face, audio-recorded semi-structured interviews about critical factors for networks' successes over the study period 2006-2008. Respondents were purposively selected from two stakeholder groups: i) chairs of networks during the study period of 2006-2008 from high- moderate- and low-impact networks (as previously determined by an independent review panel) and ii) experts in the clinical field of the network who had a connection to the network but who were not network members. Participants were blind to the performance of the network they were interviewed about. Transcribed data were coded and analysed to generate themes relating to the study aims. RESULTS: Themes relating to influential factors critical to network success were: network model principles; leadership; formal organisational structures and processes; nature of network projects; external relationships; profile and credibility of the network. CONCLUSIONS: This study provides clinical networks with guidance on essential factors for maximising optimal network outcomes and that may assist networks to move from being a 'low-impact' to 'high-impact' network. Important ingredients for successful clinical networks were visionary and strategic leadership with strong links to external stakeholders; and having formal infrastructure and processes to enable the development and management of work plans aligned with health priorities.

Clinical validation of an aggregate learning ratio from the neuropsychological assessment battery.

Quantifying learning deficits provides valuable information in identifying and diagnosing mild cognitive impairment and dementia. Previous research has found that a learning ratio (LR) metric, derived from the list learning test from the Neuropsychological Assessment Battery (NAB), was able to distinguish between those with normal cognition versus memory impairment. The current study furthers the NAB LR research by validating a NAB story LR, as well as an aggregate LR. The aggregate LR was created by combining the individual list and story LRs. Participants were classified as those with normal cognition (n = 51), those with MCI (n = 39) and those with dementia (n = 35). Results revealed the story LR was able to accurately distinguish normal controls from those with mild cognitive impairment and those with dementia and offers enhanced discriminability beyond the story immediate recall score (sum of trial 1 and trial 2). Further, the aggregate LR provided superior discriminability beyond the individual list and story LRs and accounted for additional variance in diagnostic group classification. The NAB aggregate LR provides improved sensitivity in detecting declines in impaired learning, which may assist clinicians in making diagnoses earlier in a disease process, benefiting the individual through earlier interventions.

Novel learning ratio from the NAB list learning test distinguishes between clinical groups: clinical validation and sex-related differences.

List-learning tasks provide a wealth of information about an individual's cognitive abilities: attention, encoding, storage, retrieval, recognition. A more recently developed metric, the Learning Ratio (LR), supplements information about cognitive ability and can assist the clinician in determining whether an individual has cognitive impairment. The LR is calculated by taking the difference between the individuals' raw score on the first learning trial and their raw score on the last learning trial, which is then divided by the number of words left to be learned after the first learning trial. A LR derived from the list-learning task from the Neuropsychological Assessment Battery (NAB) was evaluated to determine ability to distinguish those with normal cognition from those with mild cognitive impairment (MCI) and dementia. Results from the present study indicate the NAB LR is able to distinguish between clinical groups; recommended cutoffs for the NAB LR scores are provided. We also found a significant female sex-advantage for the NAB LR in those with normal memory ability and demonstrated the female sex advantage decreased with increasing memory impairment. Taken together, the NAB LR may assist clinicians in making an accurate and early diagnosis and may be helpful for tracking learning and functioning across multiple assessments. .

Mortality after admission for acute myocardial infarction in Aboriginal and non-Aboriginal people in New South Wales, Australia: a multilevel data linkage study.

BACKGROUND: Heart disease is a leading cause of the gap in burden of disease between Aboriginal and non-Aboriginal Australians. Our study investigated short- and long-term mortality after admission for Aboriginal and non-Aboriginal people admitted with acute myocardial infarction (AMI) to public hospitals in New South Wales, Australia, and examined the impact of the hospital of admission on outcomes. METHODS: Admission records were linked to mortality records for 60047 patients aged 25-84 years admitted with a diagnosis of AMI between July 2001 and December 2008. Multilevel logistic regression was used to estimate adjusted odds ratios (AOR) for 30- and 365-day all-cause mortality. RESULTS: Aboriginal patients admitted with an AMI were younger than non-Aboriginal patients, and more likely to be admitted to lower volume, remote hospitals without on-site angiography. Adjusting for age, sex, year and hospital, Aboriginal patients had a similar 30-day mortality risk to non-Aboriginal patients (AOR: 1.07; 95% CI 0.83-1.37) but a higher risk of dying within 365 days (AOR: 1.34; 95% CI 1.10-1.63). The latter difference did not persist after adjustment for comorbid conditions (AOR: 1.12; 95% CI 0.91-1.38). Patients admitted to more remote hospitals, those with lower patient volume and those without on-site angiography had increased risk of short and long-term mortality regardless of Aboriginal status. CONCLUSIONS: Improving access to larger hospitals and those with specialist cardiac facilities could improve outcomes following AMI for all patients. However, major efforts to boost primary and secondary prevention of AMI are required to reduce the mortality gap between Aboriginal and non-Aboriginal people.

A qualitative study of stakeholder views of the conditions for and outcomes of successful clinical networks.

BACKGROUND: Clinical networks have been established to improve health outcomes and processes of care by implementing a range of innovations and undertaking projects based on perceived local need. Limited research exists on the necessary conditions required to bring about successful network outcomes and what characterises network success from the perspective of those involved in network initiatives. This qualitative study identified stakeholder views on i) the conditions for effective clinical networks; and ii) desirable outcomes of successful clinical networks. METHODS: Twenty-seven participants were interviewed using face-to-face audio-recorded semi-structured interviews. Transcribed data were coded and analysed to generate themes relating to the study aims. RESULTS: Five key factors represented as sub-themes were identified as important conditions for the establishment of successful clinical networks under the main theme of effective network structure, organisation and governance. These were: building relationships; effective leadership; strategic evidence-based workplans; adequate resources; and ability to implement and evaluate network initiatives. Two major themes encapsulated views on desirable outcomes of successful clinical networks: connecting and engaging which represented the outcomes of interdisciplinary and consumer collaboration and, partnerships with state health and local health services, and changing the landscape of care, which represented the importance of outcomes associated with improving services, care and patient health outcomes and implementing evidence-based practice. CONCLUSIONS: This study provides new knowledge on the conditions needed to establish successful clinical networks and on desirable outcomes arising from network projects and initiatives that are considered to be valuable by those working in or associated with clinical networks. This provides health services with information on what needs to be in place for successful networks and on the types of outcomes that can be considered for assessing network effectiveness.

The effects of road traffic and aircraft noise exposure on children's episodic memory: the RANCH project.

Previous studies have found that chronic exposure to aircraft noise has a negative effect on children's performance on tests of episodic memory. The present study extended the design of earlier studies in three ways: firstly, by examining the effects of two noise sources, aircraft and road traffic, secondly, by examining exposure-effect relationships, and thirdly, by carrying out parallel field studies in three European countries, allowing cross-country comparisons to be made. A total of 2844 children aged between 8 years 10 months and 12 years 10 months (mean age 10 years 6 months) completed classroom-based tests of cued recall, recognition memory and prospective memory. Questionnaires were also completed by the children and their parents in order to provide information about socioeconomic context. Multilevel modeling analysis revealed aircraft noise to be associated with an impairment of recognition memory in a linear exposure-effect relationship. The analysis also found road traffic noise to be associated with improved performance on cued recall in a linear exposure-effect relationship. No significant association was found between exposure to aircraft noise and cued recall or prospective memory. Likewise, no significant association was found between road traffic noise and recognition or prospective memory. Taken together, these findings indicate that exposure to aircraft noise and road traffic noise can impact on certain aspects of children's episodic memory.

'Hands on, Hands off': a model of clinical supervision that recognises trainees' need for support and independence.

RATIONALE: This article presents a study of junior doctor supervision at a rural hospital. The objective of the present study was to gain insight into the types of supervision events experienced, the quality of supervisory relationships, the frequencies of supervision contact in a rural hospital setting, and the implications of these factors for supervision practice. METHODS: A cohort of junior doctors was asked to provide in-depth information about their interactions with their supervisors and other relevant clinical colleagues. The information was filled in on diary sheets to capture the nature, focus and quality of the cohort's supervision experiences over 2 weeks. The information also covered frequency and types of supervisory contacts. RESULTS: The quantitative data reveals that supervisory events occur predominantly as part of ongoing patient care and rarely off-line as part of targeted supervisory practice. The qualitative data analysis reveals that junior doctors value supervisory support of two kinds: assistance from more senior clinicians who are expert in areas where trainees need help, and trust to act independently, without being abandoned. CONCLUSION: Supervision must be both structured and dynamic. Besides providing a regular forum for discussion and reflection, supervision must accommodate the variable needs of individual junior doctors and navigate between being hands-on and hands-off. Such dynamic approach is necessary to reassure junior doctors they are in a 'zone of safe learning' where they can act with adequate and flexible support and negotiate changes in supervisory attention.

Urologists' referral and radiation oncologists' treatment patterns regarding high-risk prostate cancer patients receiving radiotherapy within 6 months after radical prostatectomy: A prospective cohort analysis.

INTRODUCTION: Previous studies have observed low rates of adjuvant radiotherapy after radical prostatectomy (RP) for high-risk prostate cancer patients. However, it is not clear the extent to which these low rates are driven by urologists' referral and radiation oncologists' treatment patterns. METHOD: The Clinician-Led Improvement in Cancer Care (CLICC) implementation trial was conducted in nine public hospitals in New South Wales, Australia. Men who underwent RP for prostate cancer during 2013-2015 and had at least one high-risk pathological feature of extracapsular extension, seminal vesicle invasion and/or positive surgical margins were included in these analyses. Outcomes were as follows: (i) referral to a radiation oncologist within 4 months after RP ('referred'); (ii) commencement of radiotherapy within 6 months after RP among those who consulted a radiation oncologist ('radiotherapy after consultation'). RESULTS: Three hundred and twenty-five (30%) of 1071 patients were 'referred', and 74 (61%) of 121 patients received 'radiotherapy after consultation'. Overall, the probability of receiving radiotherapy within 6 months after RP was 15%. The probability of being 'referred' increased according to higher 5-year risk of cancer-recurrence (P < 0.001). CONCLUSION: Only 30% of patients with high-risk features are referred to a radiation oncologist with the likelihood of referral being influenced by the perceived risk of cancer-recurrence as well as the urologist's institutional/personal preference. When patients are seen by a radiation oncologist, 61% receive radiotherapy within 6 months after RP with the likelihood of receiving radiotherapy not being heavily influenced by increasing risk of recurrence. This suggests many suitable patients would receive radiotherapy if referred and seen by a radiation oncologist.

Children's annoyance reactions to aircraft and road traffic noise.

Since annoyance reactions of children to environmental noise have rarely been investigated, no source specific exposure-response relations are available. The aim of this paper is to investigate children's reactions to aircraft and road traffic noise and to derive exposure-response relations. To this end, children's annoyance reactions to aircraft and road traffic noise in both the home and the school setting were investigated using the data gathered in a cross-sectional multicenter study, carried out among 2844 children (age 9-11 years) attending 89 primary schools around three European airports. An exposure-response relation was demonstrated between exposure to aircraft noise at school (L(Aeq,7-23 h)) and severe annoyance in children: after adjustment for confounders, the percentage severely annoyed children was predicted to increase from about 5.1% at 50 dB to about 12.1% at 60 dB. The findings were consistent across the three samples. Aircraft noise at home (L(Aeq,7-23 h)) demonstrated a similar relation with severe annoyance. Children attending schools with higher road traffic noise (L(Aeq,7-23 h)) were more annoyed. Although children were less annoyed at levels above 55 dB, the shapes of the exposure-response relations found among children were comparable to those found in their parents.

Reduction of road traffic noise and mental health: an intervention study.

Road traffic noise exposure leads to annoyance and impairment of quality of life and may impair health. If this association is causal, a reduction in noise exposure should result in a reduction in noise annoyance and improvement in quality of life. This study examines whether the reduction in road traffic noise following the introduction of a bypass leads to reduction in noise annoyance and common mental disorder and an improvement in quality of life. Repeated measures field study with intervention in three small towns in North Wales, UK. Participants were residents 16 to 90 years living in areas of high or low exposure to road traffic noise. At baseline there was no difference in annoyance, quality of life or common mental disorder between traffic noise exposed and quiet areas. There was a small reduction in noise exposure (2-4 dBA) with the opening of the bypass. There was no reduction in noise annoyance and no change in levels of common mental disorder and quality of life following the introduction of the bypass. Traffic noise reduction associated with the introduction of the bypass was not associated with measurable changes in quality of life or common mental disorder. This study suggests that reduction in traffic noise level of 3dB or less is insufficient to influence annoyance or mental health. However, the methodological difficulties of the study limit the conclusions that can be drawn on whether there is a causal effect of noise on common mental disorder.

Immediate Effects of External Vibration vs Placebo on Vocal Function Therapy in Singers: A Randomized Clinical Trial.

Importance: External vibration therapy (EVT) has been widely used in chronic pain conditions, musculoskeletal rehabilitation, and athletic training. Vibration therapy has been suggested to enhance vocal performance and has been popularized in social media. However, there is no evidence to support its effect on vocal function. Objective: To evaluate the immediate effects of EVT in trained singers using acoustic and self-assessment parameters. Design, Setting, and Participants: Prospective, randomized, placebo-controlled interventional study at St Michael's Hospital Voice Clinic, affiliated with the University of Toronto. Data collection and analysis were performed by investigators who were blinded to the group assignment of the participants. Study participants were randomized to EVT or a placebo (control) group. The study dates were September 2015 to December 2016. Interventions: Participants attended the voice laboratory at St Michael's Hospital, where a standardized data collection protocol was performed, including acoustic parameters, voice range profile, and soft voice tasks, followed by subjective rating of vocal effort or discomfort. The EVT group underwent EVT to 5 neck sites bilaterally. The placebo group underwent the same protocol with a modified device. After the intervention, the participants repeated the standardized data collection. Main Outcomes and Measures: The primary outcome in this study was acoustic analysis (jitter, shimmer, and pitch range) compared before and after treatment. In addition, secondary outcomes included perceived effort or discomfort evaluated by participants after 4 voice tasks proposed to investigate more subtle voice properties. Within and between groups, data sets were statistically analyzed for potential treatment effect. Results: Among 27 participants (age range, 18-50 years; all female), 14 were randomized to the intervention group and 13 to the placebo group. Comparison of the treatment effect on the vowel token acoustic parameters evaluated showed that, after EVT, participants had a more cohesive change with a restricted 95% CI compared with placebo. The mean change in fundamental frequency after intervention was 5.00 Hz in both groups but the 95% CI was much wider after placebo (-30.30 to 19.20) than after EVT (-18.10 to 7.50). After EVT, the effect size was notable in the vowel (0.83) and SVT3 (0.79) task. Conclusions and Relevance: In this study, EVT demonstrated a more predictable change in acoustic metrics compared with the placebo treatment. Effort ratings for 6 voice tasks evaluated in this study were not found to be different after EVT compared with the placebo treatment. Trial Registration: clinicaltrials.gov Identifier: NCT02083341.

The EXpert PANel Decision (EXPAND) method: a way to measure the impact of diverse quality improvement activities of clinical networks.

Objectives and importance of study: Evaluating impacts of quality improvement activities across diverse clinical focus areas is challenging. However, evaluation is necessary to determine if the activities had an impact on quality of care and resulted in system-wide change. Clinical networks of health providers aim to provide a platform for accelerating quality improvement activities and adopting evidence based practices. However, most networks do not collect primary data that would enable evaluation of impact. We adapted an established expert panel approach to measure the impacts of efforts in 19 clinical networks to improve care and promote health system change, to determine whether these efforts achieved their purpose. STUDY TYPE: A retrospective cross-sectional study of 19 clinical networks using multiple methods of data collection including the EXpert PANel Decision (EXPAND) method. METHODS: Network impacts were identified through interviews with network managers (n = 19) and co-chairs (n = 32), and document review. The EXPAND method brought together five independent experts who provided initial individual ratings of overall network impact. After attendance at an in-person moderated meeting where aggregate scores were discussed, the experts provided a final rating. Median scores of postmeeting ratings were the final measures of network impact. RESULTS: Among the 19 clinical networks, experts rated 47% (n = 9) as having a limited impact on improving quality of care, 37% (n = 7) as having a moderate impact and 16% (n = 3) as having a high impact. The experts rated 26% (n = 5) of clinical networks as having a limited impact on facilitating system-wide change, 37% (n = 7) as having a moderate impact and 37% (n = 7) as having a high impact. CONCLUSION: The EXPAND method enabled appraisal of diverse clinical networks in the absence of primary data that could directly evaluate network impacts. The EXPAND method can be applied to assess the impact of quality improvement initiatives across diverse clinical areas to inform healthcare planning, delivery and performance. Further research is needed to assess its reliability and validity.

A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial.

BACKGROUND: This study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations. METHODS: Nine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals' and study Sites' practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists' attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability. RESULTS: Records for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the control-phase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%). CONCLUSIONS: The intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists' attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910 ). Registered 6 December 2011.

Improving the quality of healthcare: a cross-sectional study of the features of successful clinical networks.

OBJECTIVES: Networks of clinical experts are being established internationally to help embed evidence based care in health systems. There is emerging evidence that these clinical networks can drive quality improvement programs, but the features that distinguish successful networks are largely unknown. We examined the factors that make clinical networks effective at improving quality of care and facilitating system-wide changes. METHODS: We conducted a retrospective cross-sectional study of 19 state-wide clinical networks that reflected a range of medical and surgical specialty care and were in operation from 2006 to 2008 in New South Wales, Australia. We conducted qualitative interviews with network leaders to characterise potential impacts, and conducted internet surveys of network members to evaluate external support and the organisational and program characteristics of their respective networks. The main outcome measures were median ratings of individual network impacts on quality of care and system-wide changes, determined through independent assessment of documented evidence by an expert panel. RESULTS: We interviewed 19 network managers and 32 network co-chairs; 592 network members completed internet surveys. Three networks were rated as having had high impact on quality of care, and seven as having had high impact on system-wide change. Better-perceived strategic and operational network management was significantly associated with higher ratings of impact on quality of care (coefficient estimate 0.86; 95% confidence interval [CI] 0.02, 1.69). Better-perceived leadership of the network manager (coefficient estimate 0.47; 95% CI 0.10, 0.85) and strategic and operational network management (coefficient estimate 0.23; 95% CI 0.06, 0.41) were associated with higher ratings of impact on system-wide change. CONCLUSIONS: This study represents the largest study of clinical networks undertaken to date. The results suggest that clinical networks that span the health system can improve quality of care and facilitate system-wide change. Network management and leadership, encompassing both strategic and operational elements at the organisational level, appear to be the primary influences on network success. These findings can guide future organisational and system-wide change programs and the development or strengthening of clinical networks to help implement evidence based care to improve service delivery and outcomes.

Psychological symptoms and physical health and health behaviours in adolescents: a prospective 2-year study in East London.

AIMS: To examine whether physical health and health-risk behaviours in young people are risk factors for psychological distress and depressive symptoms over a 2-year period. DESIGN/SETTING: A 2-year, prospective epidemiological cohort study in East London. PARTICIPANTS: A total of 1615 adolescents from the Research with East London Adolescents: Community Health Survey (RELACHS)-a representative cohort of young people aged 11-12 and 13-14 years at baseline, followed-up after 2 years. MEASUREMENTS: Psychological distress and depressive symptoms identified by the self-report Strengths and Difficulties Questionnaire and the Short Moods and Feelings Questionnaire at baseline and follow-up. Data on overweight/obesity, general health, long-standing illness, physical activity, smoking, alcohol use and drug use were collected from questionnaires completed by the adolescents at baseline and follow-up. FINDINGS: At follow-up, 10.1% of males and 12.9% of females reported psychological distress; 20% of males and 33.7% of females reported depressive symptoms. Having tried drugs or engaged in two or more health-risk behaviours (smoking, alcohol use or drug use) at baseline predicted psychological distress and depressive symptoms at follow-up. Smoking on its own, long-standing illness, obesity/overweight and activity levels were not associated with later psychological health. Risk of poor psychological health at follow-up was associated strongly with psychological health at baseline. CONCLUSIONS: Psychological health at baseline was the strongest predictor of psychological health at follow-up. Engaging in two or more health-risk behaviours moderately increased the risk of poor psychological health, suggesting that prevention strategies targeting co-occuring substance use may reduce burden of disease.

Improving preoperative medication compliance with standardized instructions.

BACKGROUND: Patient medication adherence in the perioperative setting is challenging, and failure to comply with medication instructions has serious clinical consequences. Many factors contribute to medication nonadherence, but a modifiable cause is inadequate physician instruction of patients. Variable formats, language and legibility impede patient-physician communication regarding proper use of medications. We hypothesized that the use of a standardized, electronic medical record (EMR)-derived medication instruction template would improve medication compliance on the day of surgery. METHODS: As part of an ongoing quality improvement program, our institution surveyed patient's compliance with preoperative medication instructions. A standardized template was then created within the EMR and implemented by all providers in the preoperative evaluation clinic. Compliance with medications on the morning of surgery was then reassessed by preoperative nursing staff for three months shortly after the intervention and again two years later. RESULTS: Patient adherence to preoperative medication instructions improved significantly immediately after the implementation of the template (from 83.7% to 89.7%, P=0.025). This improvement was also sustained at the two-year follow-up. Although patients' had overall good medication compliance (90% after the intervention), 71% of medication errors were made with medications with significant potential for causing complications (e.g., antithrombotic therapy). CONCLUSION: Use of standardized, EMR-generated preoperative instructions improves patient medication adherence on the morning of surgery. Even with this intervention, medication nonadherence most often involves medications that could seriously interfere with perioperative care.

Changing attitudes towards management of men with locally advanced prostate cancer following radical prostatectomy: A follow-up survey of Australia-based urologists.

INTRODUCTION: This study examined whether there has been change among Australia-based urologists' knowledge, attitudes and beliefs relating to guideline-recommended adjuvant radiotherapy for men with adverse pathologic features following radical prostatectomy since a prior survey in 2012 and investigated associations between attitudes and treatment preferences. METHODS: A nationwide survey of Australia-based urologist members of the Urological Society of Australia and New Zealand. RESULTS: Ninety-six respondents completed the 2015 survey (30% response rate) compared with 157 (45% response rate) in 2012. There was no significant change in awareness of national clinical practice guidelines for the management of prostate cancer. When considering adjuvant against salvage radiotherapy, urologists were significantly less favourable towards adjuvant radiotherapy in 2015 than in 2012 for two of three hypothetical clinical case scenarios with a high 10-year risk of biochemical relapse according to Memorial Sloan Kettering Cancer Center nomograms (P < 0.001 for both cases). In 2015, urologists were less positive overall towards the recommendation for post-operative adjuvant radiotherapy for men with locally advanced prostate cancer than in 2012 (P < 0.001), reflecting a significant change across a number of attitudes and beliefs. Of note, urologists felt other urologists would more likely be critical if they routinely referred the target patient group for radiotherapy in 2015 compared with 2012 (P = 0.007). CONCLUSION: In 2015 Australia-based urologists were less favourable towards adjuvant radiotherapy over watchful waiting for men with high-risk pathologic features post-prostatectomy than in 2012. We could find no new published research that precipitated this change in attitude.