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

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

Point-of-care ultrasound in general practice: an exploratory study in rural South Australia.

INTRODUCTION: Access to ultrasound imaging services is limited in rural areas and point-of-care ultrasound (POCUS) has the potential to address this gap. We aimed to examine how POCUS is utilised by doctors in contemporary Australian rural general practice. METHODS: A portable ultrasound machine and access to a training course were provided to four general practices in rural South Australia, and the type and frequency of POCUS scans were recorded, along with user information, between July 2020 and June 2021. Participating general practitioners (GPs) completed a survey at the commencement of the study regarding their previous experience and confidence in using POCUS for specific assessments and procedures. RESULTS: Of the 472 scans recorded, most (95%) were for clinical indications, 3% for teaching activities and 2% for self-learning. Overall, 69% were obstetric scans, followed by abdominal (12%), gynaecological procedures (10%), other procedural (7%) and thoracic exams (1.5%). Users reported higher confidence for lower complexity POCUS. CONCLUSION: Although POCUS has diverse potential applications in rural practice, GPs reported limited confidence for certain scans and used POCUS predominantly for obstetric indications. Further studies should examine the barriers to POCUS utilisation, with particular attention to training requirements, reimbursement for use and access to machines.

Predicted cardiovascular disease risk and prescribing of antihypertensive therapy among patients with hypertension in Australia using MedicineInsight.

Hypertension guidelines recommend that absolute cardiovascular disease (CVD) risk guide the management of hypertensive patients. This study aimed to assess the proportion of patients with diagnosed hypertension with sufficient data to calculate absolute CVD risk and determine whether CVD risk is associated with prescribing of antihypertensive therapies. This was a cross-sectional study using a large national database of electronic medical records of patients attending general practice in 2018 (MedicineInsight). Of 571,492 patients aged 45-74 years without a history of CVD, 251,733 [40.6% (95% CI: 39.8-41.2)] had a recorded hypertension diagnosis. The proportion of patients with sufficient recorded data available to calculate CVD risk was higher for patients diagnosed with hypertension [51.0% (95% CI: 48.0-53.9)] than for patients without a diagnosis of hypertension [38.7% (95% CI: 36.5-41.0)]. Of those patients with sufficient data to calculate CVD risk, 29.3% (95% CI: 28.1-30.6) were at high risk clinically, 6.0% (95% CI: 5.8-6.3) were at high risk based on their CVD risk score, 12.8% (95% CI: 12.5-13.2) at moderate risk and 51.8% (95% CI: 50.8-52.9) at low risk. The overall prevalence of antihypertensive therapy was 60.9% (95% CI: 59.3-62.5). Prescribing was slightly lower in patients at high risk based on their CVD risk score [57.4% (95% CI: 55.4-59.4)] compared with those at low [63.3% (95% CI: 61.9-64.8)] or moderate risk [61.8% (95% CI: 60.2-63.4)] or at high risk clinically [64.1% (95% CI: 61.9-66.3)]. Guideline adherence is suboptimal, and many patients miss out on treatments that may prevent future CVD events.

Muscle Strength Assessed by Handgrip Strength Moderates the Relationship Between Overweight and Obesity With Cardiometabolic Risk Markers Among Adults and Older Adults.

Background and aims: Few population-based studies have studied whether muscle strength (MS) levels influence the relationship between cardiometabolic markers with excess body weight. We investigate the possible moderator role of MS in the relationship between overweight and obesity with cardiometabolic markers. Methods: Cross-sectional analysis using data from two studies in Florianópolis, Brazil (EpiFloripa Adult Cohort Study, n = 862, 39.3 ± 11.4 years; EpiFloripa Aging Cohort Study, n = 1,197, 69.7 ± 7.1 years). MS was assessed by handgrip strength. Body mass index (BMI) was classified as overweight or obesity (BMI 25.0-29.9 or ≥30.0 kg/m2, respectively). Cardiometabolic markers included systolic (SBP) and diastolic blood pressure (DBP), C-reactive protein (CRP), lipids, glucose markers, and carotid intima-media thickness (CIMT). Linear regression models stratified by age groups (adults: <60 years; older adults: ≥60 years) and adjusted for confounders were used. Results: Compared to those with a normal BMI, overweight and obesity were related to higher SBP, DBP, lnCRP, ln triglycerides, fasting glucose (FG), and glicated hemoglobin (HbA1c), and inversely associated with HDL-C among adults and older adults (p value < .05 for all). Additionally, BMI was positively associated with LDL-C and CIMT only among adults (p value < .05). Among adults and older adults, elevated MS attenuated the adverse relationship between excess body weight with FG and HbA1c. Conclusion: Higher MS might help adults and older adults with overweight or obesity reduce their cardiovascular risk by keeping their FG and HbA1c at the same levels of those with a normal BMI.

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

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

Dietary vitamin D and calcium and periodontitis: A population-based study.

Aim: This study aimed to explore the relationship between dietary vitamin D and calcium intake and periodontitis among adults and whether it differs from males to females. Methods: Cross-sectional analysis of a population-based cohort study with adults aged 20 to 60 from Southern Brazil. Intake of vitamin D and calcium were gathered in 2012 using two 24h-dietary recalls. Clinical examination assessed the clinical attachment level and bleeding on probing. Confounders included sex, age, family income, smoking, and obesity. The controlled direct effect of vitamin D and calcium on periodontitis was examined using marginal structural modeling. Analyses were also stratified by sex. Results: Of the 1,066 investigated adults (mean age 35 ± 11.7 years; 49% females), 12.3% (95%CI 10.2;14.7) had periodontitis. Calcium intake had a direct protective effect on periodontitis (risk ratio (RR) 0.61; 95%CI 0.45;0.83), whereas no association between vitamin D and periodontitis was observed (RR 1.13; 95%CI 0.82;1.56). Stratified analyses revealed a null association between both vitamin D and calcium intake and periodontitis among men, but a protective association between calcium and intake and periodontitis among women (RR 0.56; 95%CI 0.38;0.79), while vitamin D remained without any association (RR 1.07; 95%CI 0.72;1.61). Conclusion: Our findings suggest a protective association between dietary calcium intake and periodontitis among women.

Trajectories of physical health-related quality of life and the risk of incident cardiovascular disease events and all-cause mortality in older people.

Study objective: The aim of this study was to identify whether physical component score (PCS) of health-related quality of life trajectories over 4.7-years predicted subsequent risk of incident fatal and non-fatal CVD events, and all-cause mortality. Methods: This study included 16,871 community-dwelling people aged ≥65 years enrolled in the ASPREE (ASPirin in Reducing Events in the Elderly) trial. PCS was assessed annually using the SF-12 (version-2) over a median 4.7-years (i.e. from baseline (2010-2014) till June 2017). Incident CVD events and all-cause mortality occurring after June 2017 until the second-year after the end of the trial were considered. Growth mixture and logistic regression modelling were used. Results: Four PCS trajectories were identified: high (66.5%), intermediate (13.3%), decline (13.8%), and low (6.5%), and there was subsequently a total of 406 (2.50%) incident CVD events, 197 (1.17%) fatal CVD, and 751 (4.45%) deaths. The declining PCS trajectory group had the highest risk of incident CVD (adjusted OR, 1.51; 95% CI 1.14, 1.99), while the low PCS trajectory group had the greatest risk of fatal CVD (adjusted OR, 1.74; 95%CI 1.06, 2.85) and all-cause mortality (adjusted OR, 1.83; 95%CI 1.40, 2.40). After further adjustment for the baseline PCS score, only the association between declining PCS trajectory and incident CVD (adjusted OR, 1.51; 95%CI 1.11, 2.07) remained. Conclusion: Our study strengthens the importance of PCS as a predictive measure of CVD and all-cause mortality in older people and also highlights that a declining PCS trajectory could be considered an early predictor of future CVD events.

Health-related quality of life and incident cardiovascular disease events in community-dwelling older people: A prospective cohort study.

BACKGROUND: Lower health-related quality of life (HRQoL) has been shown to predict a higher risk of hospital readmission and mortality in patients with cardiovascular disease (CVD). Few studies have explored the associations between HRQoL and incident CVD. We explored the associations between baseline HRQoL and incident and fatal CVD in community-dwelling older people in Australia and the United States. METHODS: Longitudinal study using ASPirin in Reducing Events in the Elderly (ASPREE) trial data. This includes 19,106 individuals aged 65-98 years, initially free of CVD, dementia, or disability, and followed between March 2010 and June 2017. The physical (PCS) and mental component scores (MCS) of HRQoL were assessed using the SF-12 questionnaire. Incident major adverse CVD events included fatal CVD (death due to atherothrombotic CVD), hospitalizations for heart failure, myocardial infarction or stroke. Analyses were performed using Cox proportional-hazard regression. RESULTS: Over a median 4.7 follow-up years, there were 922 incident CVD events, 203 fatal CVD events, 171 hospitalizations for heart failure, 355 fatal or nonfatal myocardial infarction and 403 fatal or nonfatal strokes. After adjustment for sociodemographic, health-related behaviours and clinical measures, a 10-unit higher PCS, but not MCS, was associated with a 14% lower risk of incident CVD, 28% lower risk of hospitalization for heart failure and 15% lower risk of myocardial infarction. Neither PCS nor MCS was associated with fatal CVD events or stroke. CONCLUSION: Physical HRQoL can be used in combination with clinical data to identify the incident CVD risk among older individuals.

Individual and Combined Association Between Healthy Lifestyle Habits With Muscle Strength According to Cardiovascular Health Status in Adults and Older Adults.

BACKGROUND: The authors aimed to identify the effect of adherence to healthy lifestyle habits on muscle strength (MS) according to a distinct health status. METHODS: Longitudinal analysis using data from 2 population-based cohorts in Brazil (EpiFloripa adult, n = 862, 38.8 [11.4] y-6 y of follow-up length; EpiFloripa Aging, n = 1197, 69.7 [7.1] y-5 y of follow-up length). MS was assessed by handgrip strength (kgf). Information assessed by questionnaire regarding adequate physical activity levels, regular consumption of fruit and vegetables, low alcohol consumption, and nonsmoking habits were analyzed in the relationship with MS according to the health status. The participants were grouped into 3 health status categories: (1) with cardiovascular disease (CVD); (2) at risk of CVD (abdominal obesity or overweight/obesity, high blood pressure, hyperglycemia, and dyslipidemia); and (3) healthy individuals (without CVD and risk of CVD). RESULTS: Simultaneous adherence of 4 healthy lifestyle habits was directly associated with MS among healthy individuals (ß = 10.0, 95% CI, 2.0-18.0, SE = 4.0), at risk of CVD (ß = 5.5, 95% CI, 0.3-12.6, SE = 3.6), and those with CVD (ß = 11.4, 95% CI, 5.8-16.7, SE = 2.8). CONCLUSIONS: Adopting a healthy lifestyle can contribute to increased MS in adults and older adults, regardless of health status.

Blood pressure control in Australian general practice: analysis using general practice records of 1.2 million patients from the MedicineInsight database.

INTRODUCTION: Hypertension is mostly managed in primary care. This study investigated the prevalence of diagnosed hypertension in Australian general practice and whether hypertension control is influenced by sociodemographic characteristics, duration since diagnosis or prescription of antihypertensive medications. METHODS: Cross-sectional study using a large national database of electronic medical records of patients attending general practice in 2017 (MedicineInsight). RESULTS: Of 1.2 million 'regular' patients (one or more consultations per year in every year from 2015 to 2017), 39.8% had a diagnosis of hypertension (95% confidence interval 38.7-40.9). Of these, 85.3% had their blood pressure (BP) recorded in 2017, and 54.9% (95% confidence interval 54.2-55.5) had controlled hypertension (<140/90 mmHg). BP control was lower in females (54.1%) compared with males (55.7%) and in the oldest age group (52.0%), with no differences by socioeconomic status. Hypertension control was lower among 'regular' patients recently diagnosed (6-12 months = 48.6% controlled) relative to those more than 12 months since diagnosis (1-2 years = 53.6%; 3-5 years 55.5%; >5 years = 55.0%). Among recently diagnosed 'regular' patients, 59.2% had no record of being prescribed antihypertensive therapy in the last 6 months of the study, of which 44.3% had controlled hypertension. For those diagnosed more than 5 years ago, 37.4% had no record of being prescribed antihypertensive patients, and 56% had normal BP levels. CONCLUSION: Although the prevalence of hypertension varied by socidemographics, there were no differences in BP assessment or control by socioeconomic status. Hypertension control remains a challenge in primary care, and electronic medical records provide an opportunity to assess hypertension management.

The Utility of Assessing Health-Related Quality of Life to Predict Cognitive Decline and Dementia.

BACKGROUND: Health-related quality of life (HRQoL) has been shown to predict adverse health outcome in the general population. OBJECTIVE: We examined the cross-sectional association between HRQoL and cognitive performance at baseline. Next, we explored whether baseline HRQoL predicted 5-year incident cognitive decline and dementia and whether there were gender differences. METHODS: 19,106 community-dwelling participants from the ASPirin in Reducing Events in the Elderly (ASPREE) trial, aged 65-98 years, free of major cognitive impairments, and completed the HRQoL 12-item short-form (SF-12) at baseline (2010-2014), were followed until June 2017. The physical (PCS) and mental component scores (MCS) of SF-12 were calculated. The cognitive tests were assessed at baseline, year 1, 3, 5, and 7 or close-out visit. Cognitive decline was defined as > 1.5 SD drop from baseline on any of the cognitive tests. Dementia was adjudicated according to DSM-IV criteria. Linear and Cox proportional-hazards regressions were used to examine the cross-sectional and longitudinal associations respectively. RESULTS: At baseline, higher PCS and MCS were associated with better cognition. Over a median 4.7-year follow-up, higher MCS was associated with a reduced risk of cognitive decline and dementia (12% and 15% respectively, per 10-unit increase) and a 10-unit higher PCS was associated with a 6% decreased risk of cognitive decline. PCS did not predict dementia incidence. Findings were not different by gender. CONCLUSION: Our study found that higher HRQoL, in particular MCS, predicted a reduced risk of cognitive decline and dementia over time in community-dwelling older people.

Health-related quality of life and all-cause mortality among older healthy individuals in Australia and the United States: a prospective cohort study.

PURPOSE: Previous research has demonstrated that lower health-related quality of life (HRQoL) is associated with higher morbidity and mortality, especially in-patient groups. The association of HRQoL with all-cause mortality in community samples requires further investigation. This study aimed to examine whether HRQoL predicts all-cause mortality in older healthy community-dwelling people from Australia and the United States (U.S.) enrolled in the Aspirin in Reducing Events in the Elderly (ASPREE) trial. We also explored whether this association varies by gender or country. METHOD: A prospective cohort of 19,106 individuals aged 65-98 years, who were without a dementia diagnosis or a known major life-limiting disease, and completed the 12-item short-form-HRQoL at recruitment (2010-2014). They were followed until June 2017. Cox proportional-hazard models were used to determine the association between the physical (PCS) and mental component scores (MCS) of HRQoL and all-cause mortality, adjusting for sociodemographic factors, health-related behaviours and clinical measures. Hazards ratios were estimated for every 10-unit increase in PCS or MCS. RESULTS: There were 1052 deaths over a median 4.7-years (interquartile range 3.6-5.7) of follow-up, with 11.9 events per 1000 person-years. Higher PCS was associated with lower all-cause mortality (HR 0.83, 95% CI 0.77, 0.89) in the entire sample, while higher MCS was associated with lower mortality among U.S. participants only (HR 0.78, 95% CI 0.63, 0.95). Gender differences in the association of either PCS or MCS with mortality were not observed. CONCLUSION: Our large study provides evidence that HRQoL is inversely associated with all-cause mortality among initially healthy older people.

Health care need and health disparities: Findings from the Regional South Australia Health (RESONATE) survey.

Regional South Australia has some of the highest rates of psychological distress, chronic disease and multimorbidity of any Australian State or Territory. Yet, the healthcare needs of this population are still not completely understood. To better understand the healthcare needs of regional South Australians, we invited adults living in the region to complete the 44-item consumer utilisation, expectations and experiences of healthcare instrument (CONVERSATIONS), online or in hard-copy. The survey was conducted between April 2017 and March 2018. A multi-modal recruitment campaign was utilised to promote the survey. We examined associations between study outcomes and remoteness area, and drew comparisons between our findings and other surveys reporting pertinent outcomes in the urban SA population. The questionnaire was completed by 3,926 adults (52.5% females; 37.6% aged 60 + years). Among the 264 distinct health conditions reported by participants, the most prevalent were hypertension (31.6%), depression (25.7%), anxiety (23.5%) and hypercholesterolaemia (22.9%). The lifetime prevalence of these conditions among participants exceeded rates reported in urban SA. The largest regional-urban health disparities were observed for eczema/dermatitis, skin cancer, other cancer types and cataracts, where prevalence rates were 2075%, 400%, 373% and 324% higher, respectively, than that reported in urban SA. Participants also reported higher levels of multimorbidity (37.7% higher) relative to urban South Australians. By contrast, participants appeared to be exposed to fewer lifestyle risk behaviours (e.g. smoking, alcohol, inadequate fruit or vegetable intake) than their urban counterparts. In summary, there was a high level of healthcare need, and considerable health disparity among participants when compared with urban settings (particularly for skin and eye conditions). These findings highlight the need for a more targeted approach to delivering health services and health promotion activities in regional areas.

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. STUDY DESIGN: Rapid review of articles published between January 2000 and May 2020. DATA SOURCES: We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. DATA SYNTHESIS: Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. CONCLUSION: Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. STUDY DESIGN: We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. DATA SOURCES: We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. DATA SYNTHESIS: Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. CONCLUSION: There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. STUDY DESIGN: Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. DATA SOURCES: We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. DATA SYNTHESIS: Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. CONCLUSION: We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. STUDY DESIGN: Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km2 . DATA SOURCES: We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. DATA SYNTHESIS: We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). CONCLUSION: Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. STUDY DESIGN: We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. DATA SOURCES: We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. DATA SYNTHESIS: During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. CONCLUSION: We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. STUDY DESIGN: Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. DATA SOURCES: English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing,deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. DATA SYNTHESIS: Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. CONCLUSION: Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Quality of life and mortality in the general population: a systematic review and meta-analysis.

BACKGROUND: Quality of life (QoL) is multi-dimensional concept of an individual' general well-being status in relation to their value, environment, cultural and social context in which they live. This study aimed to quantitatively synthesise available evidence on the association between QoL and mortality in the general population. METHODS: An electronic search was conducted using three bibliographic databases, MEDLINE, EMBASE and PsycINFO. Inclusion criteria were studies that assessed QoL using standardized tools and examined mortality risk in a non-patient population. Qualitative data synthesis and meta-analyses using a random-effects model were performed. RESULTS: Of 4184 articles identified, 47 were eligible for inclusion, involving approximately 1,200,000 participants. Studies were highly heterogeneous in terms of QoL measures, population characteristics and data analysis. In total, 43 studies (91.5%) reported that better QoL was associated with lower mortality risk. The results of four meta-analyses indicated that higher health-related QoL (HRQoL) is associated with lower mortality risk, which was consistent for overall HRQoL (HR 0.633, 95% CI: 0.514 to 0.780), physical function (HR 0.987, 95% CI: 0.982 to 0.992), physical component score (OR 0.950, 95% CI: 0.935 to 0.965), and mental component score (OR 0.980, 95% CI: 0.969 to 0.992). CONCLUSION: These findings provide evidence that better QoL/HRQoL was associated with lower mortality risk. The utility of these measures in predicting mortality risk indicates that they should be considered further as potential screening tools in general clinical practice, beyond the traditional objective measures such as body mass index and the results of laboratory tests.

Clusters of cardiovascular risk factors and its association with muscle strength in adults.

BACKGROUND: Cardiovascular diseases are the leading cause of death globally. The aim of the study was to investigate the relationship between muscle strength (MS) and clusters of metabolic syndrome (MetS) components in adults. METHODS: Population-based cross-sectional study comprising 533 adults (45.3±11.1 years) from Florianópolis, Brazil. MS - calculated as the ratio between absolute strength (kgf) and body mass (kg) - was measured by handgrip dynamometry. Data on blood pressure, waist circumference, lipids and blood glucose were used to identify MetS components that were analyzed as individual variables and clusters. Multiple linear regression adjusted was used. RESULTS: Individually, MS was inversely associated with all MetS components (1, 2, 3 and 4 factors, ß of at least -0.08 kgf/kg). In addition, MS was negatively associated with number of positive MetS components (1, 2, 3 and 4 factors; ß of at least -0.05 kgf/kg). Individually or combined in clusters of two, three and four risk factors (ß of at least -0.20 kgf/kg), abdominal obesity was directly associated with lower MS values. All combinations of 3 and 4 MetS components (ß of at least -0.13 kgf/kg) were inversely associated with MS. CONCLUSIONS: Greater number of individual MetS components were related to lower MS values.

Gout, flares, and allopurinol use: a population-based study.

BACKGROUND: There is a paucity of community-based data regarding the prevalence and impact of gout flares as these may often be self-managed. The aim of this study was to determine the prevalence of self-reported gout and gout flares, the use of urate-lowering therapy (ULT), and the association of gout flares with health-related quality of life (HRQoL) in a large community sample. Covariate associations with flare frequency and allopurinol use were also examined. METHODS: The South Australian Health Omnibus Survey is an annual, face-to-face population-based survey. Data collected in the 2017 survey included self-reported medically diagnosed gout, allopurinol use (first-line ULT in Australia), and gout attacks (flares) in the last 12 months, in addition to sociodemographic variables and health-related quality of life (HRQoL, SF-12). Data were weighted to the Australian Bureau of Statistics 2016 census data to reflect the South Australian population. Participants 25 years and over (n = 2778) were included in the analysis. RESULTS: The prevalence of gout was 6.5% (95%CI 5.5, 7.5). Amongst participants with gout, 37.1% (95%CI 29.6, 45.3) reported currently using allopurinol, while 23.2% (95%CI 16.9, 21.0) reported prior use (38% discontinuation rate). Frequent flares (≥ 2 in the last year) were reported by 25% of participants with gout and were more likely with younger age, higher body mass index, and current allopurinol use (p < 0.05). The frequency of gout flares was associated with a lower physical HRQoL (p = 0.012). Current allopurinol use was reported by 51% of participants with frequent gout flares. CONCLUSION: Flares were frequently reported by people with gout in the community. Gout flares were associated with reduced physical HRQoL. Almost one half of people with frequent gout flares were not receiving allopurinol, and current allopurinol use was associated with frequent gout flares, suggesting undertreated disease and suboptimal use of ULT. Determining covariate associations with flares and ineffective allopurinol use may identify means of improving treatment and reducing flares.

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

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

Clinical Significance of Serum Adiponectin and Resistin Levels in Liver Cirrhosis.

INTRODUCTION: Adiponectin and resistin levels are increased in patients with cirrhosis, but it prognostic significance is unknown. We sought to investigate the factors associated with adiponectin and resistin levels and its clinical significance in patients with cirrhosis. MATERIALS AND METHODS: This was a prospective cohort study that included 122 subjects with cirrhosis who attended an outpatient clinic and were initially evaluated in 2012. Serum adiponectin and resistin levels were measured in samples collected in 2012 (adiponectin and resistin) and 2014 (adiponectin). Thirty healthy subjects served as a control group. RESULTS: Higher adiponectin (21.59 µ g/mL vs. 12.52 µg/mL, P < 0.001) and resistin levels (3.83 ng/mL vs. 2.66 ng/mL, P < 0.001) were observed among patients with cirrhosis compared to controls. Patients classified as Child-Pugh B/C had higher adiponectin levels in relation to Child-Pugh A patients. At second measurement, adiponectin levels increased significantly in non-transplant patients and decreased in liver transplant recipients. Univariate Cox analysis showed that among patients with alcoholic liver disease, adiponectin levels were associated with lower transplant-free survival (HR = 1.034, 95% CI 1.006 - 1.062, P = 0.016). The transplant-free survival was significantly lower among patients with alcoholic liver disease and adiponectin ≥ 17 µg/mL (26.55 months, 95% CI 21.40-31.70) as compared to those with levels < 17 µg/mL (33.76 months, 95% CI 30.70-36.82) (P = 0.045). No relationship was found between the levels of resistin and survival. CONCLUSION: Adiponectin but not resistin levels were associated with intensity of liver dysfunction and worse prognosis in patients with alcoholic liver disease, suggesting a potential as a prognostic biomarker.