Using the Tasmanian Palliative and End of Life Care Policy Framework (2022) to assess service delivery in a rural general practice.

AIMS: This commentary uses the Tasmanian Palliative and End of Life Care Policy Framework (2022; the TPE Framework) to reflect upon palliative care services delivered by a rural Tasmanian general practice. CONTEXT: Rural populations have challenges in accessing many healthcare services, including palliative care. General practitioners (GPs) and other primary healthcare workers are frequently relied upon to deliver palliative care in rural Australia. Palliative care is often needed before the end-of-life phase and patients prefer this to be delivered in the community or at home. GPs face challenges and barriers in continuing to deliver home-based palliative care services. APPROACH: All Medical Benefit Scheme billings for after-hours or home-based palliative care provided by the practice, between September 2021 and August 2022, were identified and patient demographic and clinical details collated. To further understand this data, nine GPs were surveyed to explore their attitudes to provision of palliative care service to the local rural communities they serve. These data highlighted several priority areas of the TPE Framework. The TPE Framework is used here to add to the shared understanding of palliative care service delivery in a rural community, and to see if GP's responses align with the priorities of the TPE Framework. Of the 258 after-hours and home-visits delivered over a 12-month period, almost 58% (n = 150) were for palliative care. Patients receiving palliative care were generally older than non-palliative patients visited (79.9 years vs. 72.0 years respectively; p = 0.004). Patients not at imminent risk of death (64.0%) were more frequently recipients of home-visits. Of the nine GPs responding to the survey, most intended to continue home visits for palliative patients. Disincentives to providing palliative care during home visits included a lack of time during the day (or after hours), low levels of interdisciplinary coordination or role-definition, and inadequate remuneration. CONCLUSION: Existing frameworks can be used as an implementation and evaluation guide to help understand local palliative care services. Using a Framework, a rural general practice in Tasmania reflected on their provision of palliative care services. Providing holistic palliative care services from a rural general practice is desirable and achievable with a coordinated, team-based approach. Access to and integration with specialist services remains a key component of community-based palliative care pathways.

Potentially preventable hospitalisations in rural community-dwelling patients.

BACKGROUND: Potentially preventable hospitalisations (PPH) are a common occurrence. Knowing the factors associated with PPH may allow high-risk patients to be identified and healthcare resources to be better allocated, and these factors may differ between urban and rural locations. AIM: To determine factors associated with PPH in an Australian rural population. METHODS: A retrospective review of admitted patients' demographic and clinical data was used to describe and model the factors associated with PPH, using an age- and sex-matched control group of non-admitted patients. This study is based in a multi-site rural general practice, Tasmania. The study included patients aged ≥18 years residing in the Huon-Bruny Island region of Tasmania, who were active patients at a rural general practice and were admitted to a public hospital for a PPH between 1 July 2016 and 30 June 2019. Main outcome measure is overnight admission to hospital for a PPH. RESULTS: Predictors with a significant odds ratio (OR) in the final model were being single/unmarried (OR 2.43; 95% confidence interval (CI) 1.38-4.28), higher Charlson Comorbidity Index score (OR 1.40; 95% CI 1.13-1.74) and the number of general practice visits in the preceding 12 months (OR 1.09; 95% CI 1.05-1.14). CONCLUSIONS: This study found that being single and having a higher comorbidity burden were the strongest independent risk factors for PPH in a rural population. Demographic and socioeconomic factors appeared to be as, if not more, important than medical factors and warrant attention when considering the design of programmes to reduce PPH risk in rural communities.

Rural Patients' Perceptions of Their Potentially Preventable Hospitalisation: A Qualitative Study.

Potentially preventable hospitalisations (PPHs) occur when patients receive hospital care for a condition that could have been more appropriately managed in the primary healthcare setting. It is anticipated that the causes of PPHs in rural populations may differ from those in urban populations; however, this is understudied. Semi-structured interviews with 10 rural Australian patients enabled them to describe their recent PPH experience. Reflexive thematic analysis was used to identify the common factors that may have led to their PPH. The analysis revealed that most participants had challenges associated with their health and its optimal self-management. Self-referral to hospital with the belief that this was the only treatment option available was also common. Most participants had limited social networks to call on in times of need or ill health. Finally, difficulty in accessing primary healthcare, especially urgently or after-hours, was described as a frequent cause of PPH. These qualitative accounts revealed that patients describe nonclinical risk factors as contributing to their recent PPH and reinforces that the views of patients should be included when designing interventions to reduce PPHs.

Healthcare Providers' Perceptions of Potentially Preventable Rural Hospitalisations: A Qualitative Study.

Potentially preventable hospitalisations (PPHs) are common in rural communities in Australia and around the world. Healthcare providers have a perspective on PPHs that may not be accessible by analysing routine patient data. This study explores the factors that healthcare providers believe cause PPHs and seeks to identify strategies for preventing them. Physicians, nurses, paramedics, and health administrators with experience in managing rural patients with PPHs were recruited from southern Tasmania, Australia. Semi-structured telephone interviews were conducted, and reflexive thematic analysis was used to analyse the data. Participants linked health literacy, limited access to primary care, and perceptions of primary care services with PPH risk. The belief that patients did not have a good understanding of where, when, and how to manage their health was perceived to be linked to patient-specific health literacy challenges. Access to primary healthcare was impacted by appointment availability, transport, and financial constraints. In contrast, it was felt that the prompt, comprehensive, and free healthcare delivered in hospitals appealed to patients and influenced their decision to bypass rural primary healthcare services. Strategies to reduce PPHs in rural Australian communities may include promoting health literacy, optimising the delivery of existing services, and improving social support structures.

A comparative analysis of policies addressing rural oral health in eight English-speaking OECD countries.

INTRODUCTON: Oral health is fundamental to overall health. Poor oral health is largely preventable but unacceptable inequalities exist, particularly for people in rural areas. The issues are complex. Rural populations are characterised by lower rates of health insurance, higher rates of poverty, less water fluoridation, fewer dentists and oral health specialists, and greater distances to access care. These factors inter-relate with educational, attitudinal, and system-level issues. An important area of enquiry is whether and how national oral health policies address causes and solutions for poor rural oral health. The purpose of this study was to examine a series of government policies on oral health to (i) determine the extent to which such policies addressed rural oral health issues, and (ii) identify enabling assumptions in policy language about problems and solutions regarding rural communities. METHODS: Eight current oral health policies were identified from Australia, New Zealand, Canada, the USA, England, Scotland, Northern Ireland, and Wales. Validated content and critical discourse analyses were used to document and explore the concepts in these policy documents, with a particular focus on the frequency with which rural oral health was mentioned, and the enabling assumptions in policy language about rural communities. RESULTS: Seventy-three concepts relating to oral health were identified from the textual analysis of the eight policy documents. The rural concept addressing oral health issues occurred in only 2% of all policies and was notably absent from the oral health policies of countries with substantial rural populations. It occurred most frequently in the policy documents from Australia and Scotland, less so in the policy documents from Canada, Wales, and New Zealand, and not at all in the oral health policies from the US, England, and Northern Ireland. Thus, the oral health needs of rural communities were generally not the focus of, nor included in, the oral health policy documents in this study. When the language of concepts related to rural oral health was examined, the qualitative analysis identified four discourse themes related to both causality and solutions. These ranked discourse themes focused on service models, workforce issues, social determinants of health, and prevention. None of the policies addressed the structural economic determinants of unequal rural oral health, nor did they specifically assert the rights of children in rural communities to equitable oral health care. CONCLUSIONS: This study documented the limited focus on rural oral health that existed in national oral health policies from eight different English-speaking countries. It supports the need for an increased focus on rural oral health issues in oral health policies, particularly as increased oral health is clearly associated with increased general health. It speaks to the critical importance of periodic analysis of the content of oral health policies to ensure that issues of inequality are addressed. Further, it reinforces the need for research findings about effective oral health care to be translated into practice in the development of practical and financially viable policies to make access to oral health care more equitable, particularly for people living in rural and remote areas.

A circle of silence: The attitudes of patients older than 65 years of age to ceasing long-term sleeping tablets.

BACKGROUND: Nocturnal benzodiazepines have a significant negative health impact on the elderly, yet they continue to be used. OBJECTIVE: The aim of this study was to assess elderly patients' use and knowledge of nocturnal benzodiazepines, and their attitudes to cessation. METHODS: Semi-structured telephone interviews were conducted with elderly patients (n = 17) from four general practices in Australia. RESULTS: Our study found that the initiation of benzodiazepine use was often at a time of stress for the patient. Long-term use was not in-tended, and patients conveyed poor awareness of the side effects and addictive potential of benzodiazepines. Patients' perceived attitudes of their general practitioner (GP) to prescribing benzodiazepines and lack of awareness of alternative therapies were key to continuation. Confounding factors such as pain often contributed to sleep disturbance. Many patients expressed a willingness to cease nocturnal benzodiazepine use. DISCUSSION: These data assist in raising GPs' awareness of patients' attitudes to cessation of nocturnal benzodiazepine use. More time spent with patients presenting for repeat prescriptions, explaining side effects, discussing alternative options and investigating reasons for not sleeping could reduce benzodiazepine use among the elderly.

Evidence in clinical reasoning: a computational linguistics analysis of 789,712 medical case summaries 1983-2012.

BACKGROUND: Better understanding of clinical reasoning could reduce diagnostic error linked to 8% of adverse medical events and 30% of malpractice cases. To a greater extent than the evidence-based movement, the clinical reasoning literature asserts the importance of practitioner intuition­unconscious elements of diagnostic reasoning. The study aimed to analyse the content of case report summaries in ways that explored the importance of an evidence concept, not only in relation to research literature but also intuition. METHODS: The study sample comprised all 789,712 abstracts in English for case reports contained in the database PUBMED for the period 1 January 1983 to 31 December 2012. It was hypothesised that, if evidence and intuition concepts were viewed by these clinical authors as essential to understanding their case reports, they would be more likely to be found in the abstracts. Computational linguistics software was used in 1) concept mapping of 21,631,481 instances of 201 concepts, and 2) specific concept analyses examining 200 paired co-occurrences for 'evidence' and research 'literature' concepts. RESULTS: 'Evidence' is a fundamentally patient-centred, intuitive concept linked to less common concepts about underlying processes, suspected disease mechanisms and diagnostic hunches. In contrast, the use of research literature in clinical reasoning is linked to more common reasoning concepts about specific knowledge and descriptions or presenting features of cases. 'Literature' is by far the most dominant concept, increasing in relevance since 2003, with an overall relevance of 13% versus 5% for 'evidence' which has remained static. CONCLUSIONS: The fact that the least present types of reasoning concepts relate to diagnostic hunches to do with underlying processes, such as what is suspected, raises questions about whether intuitive practitioner evidence-making, found in a constellation of dynamic, process concepts, has become less important. The study adds support to the existing corpus of research on clinical reasoning, by suggesting that intuition involves a complex constellation of concepts important to how the construct of evidence is understood. The list of concepts the study generated offers a basis for reflection on the nature of evidence in diagnostic reasoning and the importance of intuition to that reasoning.

Health adaptation policy for climate vulnerable groups: a 'critical computational linguistics' analysis.

BACKGROUND: Many countries are developing or reviewing national adaptation policy for climate change but the extent to which these meet the health needs of vulnerable groups has not been assessed. This study examines the adequacy of such policies for nine known climate-vulnerable groups: people with mental health conditions, Aboriginal people, culturally and linguistically diverse groups, aged people, people with disabilities, rural communities, children, women, and socioeconomically disadvantaged people. METHODS: The study analyses an exhaustive sample of national adaptation policy documents from Annex 1 ('developed') countries of the United Nations Framework Convention on Climate Change: 20 documents from 12 countries. A 'critical computational linguistics' method was used involving novel software-driven quantitative mapping and traditional critical discourse analysis. RESULTS: The study finds that references to vulnerable groups are relatively little present or non-existent, as well as poorly connected to language about practical strategies and socio-economic contexts, both also little present. CONCLUSIONS: The conclusions offer strategies for developing policy that is better informed by a 'social determinants of health' definition of climate vulnerability, consistent with best practice in the literature and global policy prescriptions.

Understanding the research-policy divide for oral health inequality.

BACKGROUND: No studies exist of the congruence of research in oral health to policy. This study aimed to examine the broad congruence of oral health research to policy, and implications for developing oral health research that is more policy relevant, particularly for the wider challenge of addressing unequal oral health outcomes, rather than specific policy translation issues. METHODS: Bayesian-based software was used in a multi-layered method to compare the conceptual content of 127,193 oral health research abstracts published between 2000-2012 with eight current oral health policy documents from Organisation for Economic Co-operation and Development countries. FINDINGS: Fifty-five concepts defined the research abstracts, of which only eight were policy-relevant, and six of which were minor research concepts. CONCLUSIONS: The degree of disconnection between clinical concepts and healthcare system and workforce development concepts was striking. This study shows that, far from being "lost in translation," oral health research and policy are so different as to raise doubts about the extent to which research is policy-relevant and policy is research-based. The notion of policy relevance encompasses the lack of willingness of policy makers to embrace research, and the need for researchers to develop research that is, and is seen to be, policy-relevant.

The evidence-policy divide: a 'critical computational linguistics' approach to the language of 18 health agency CEOs from 9 countries.

BACKGROUND: There is an emerging body of literature suggesting that the evidence-practice divide in health policy is complex and multi-factorial but less is known about the processes by which health policy-makers use evidence and their views about the specific features of useful evidence. This study aimed to contribute to understandings of how the most influential health policy-makers view useful evidence, in ways that help explore and question how the evidence-policy divide is understood and what research might be supported to help overcome this divide. METHODS: A purposeful sample of 18 national and state health agency CEOs from 9 countries was obtained. Participants were interviewed using open-ended questions that asked them to define specific features of useful evidence. The analysis involved two main approaches 1)quantitative mapping of interview transcripts using Bayesian-based computational linguistics software 2)qualitative critical discourse analysis to explore the nuances of language extracts so identified. RESULTS: The decision-making, conclusions-oriented world of policy-making is constructed separately, but not exclusively, by policy-makers from the world of research. Research is not so much devalued by them as described as too technical- yet at the same time not methodologically complex enough to engage with localised policy-making contexts. It is not that policy-makers are negative about academics or universities, it is that they struggle to find complexity-oriented methodologies for understanding their stakeholder communities and improving systems. They did not describe themselves as having a more positive role in solving this challenge than academics. CONCLUSIONS: These interviews do not support simplistic definitions of policy-makers and researchers as coming from two irreconcilable worlds. They suggest that qualitative and quantitative research is valued by policy-makers but that to be policy-relevant health research may need to focus on building complexity-oriented research methods for local community health and service development. Researchers may also need to better explain and develop the policy-relevance of large statistical generalisable research designs. Policy-makers and public health researchers wanting to serve local community needs may need to be more proactive about questioning whether the dominant definitions of research quality and the research funding levers that drive university research production are appropriately inclusive of excellence in such policy-relevant research.

Understanding and benchmarking health service achievement of policy goals for chronic disease.

BACKGROUND: Key challenges in benchmarking health service achievement of policy goals in areas such as chronic disease are: 1) developing indicators and understanding how policy goals might work as indicators of service performance; 2) developing methods for economically collecting and reporting stakeholder perceptions; 3) combining and sharing data about the performance of organizations; 4) interpreting outcome measures; 5) obtaining actionable benchmarking information. This study aimed to explore how a new Boolean-based small-N method from the social sciences-Qualitative Comparative Analysis or QCA-could contribute to meeting these internationally shared challenges. METHODS: A 'multi-value QCA' (MVQCA) analysis was conducted of data from 24 senior staff at 17 randomly selected services for chronic disease, who provided perceptions of 1) whether government health services were improving their achievement of a set of statewide policy goals for chronic disease and 2) the efficacy of state health office actions in influencing this improvement. The analysis produced summaries of configurations of perceived service improvements. RESULTS: Most respondents observed improvements in most areas but uniformly good improvements across services were not perceived as happening (regardless of whether respondents identified a state health office contribution to that improvement). The sentinel policy goal of using evidence to develop service practice was not achieved at all in four services and appears to be reliant on other kinds of service improvements happening. CONCLUSIONS: The QCA method suggested theoretically plausible findings and an approach that with further development could help meet the five benchmarking challenges. In particular, it suggests that achievement of one policy goal may be reliant on achievement of another goal in complex ways that the literature has not yet fully accommodated but which could help prioritize policy goals. The weaknesses of QCA can be found wherever traditional big-N statistical methods are needed and possible, and in its more complex and therefore difficult to empirically validate findings. It should be considered a potentially valuable adjunct method for benchmarking complex health policy goals such as those for chronic disease.

Climate change: could it help develop 'adaptive expertise'?

Preparing health practitioners to respond to the rising burden of disease from climate change is emerging as a priority in health workforce policy and planning. However, this issue is hardly represented in the medical education research. The rapidly evolving wide range of direct and indirect consequences of climate change will require health professionals to have not only broad content knowledge but also flexibility and responsiveness to diverse regional conditions as part of complex health problem-solving and adaptation. It is known that adaptive experts may not necessarily be quick at solving familiar problems, but they do creatively seek to better solve novel problems. This may be the result of an acquired approach to practice or a pathway that can be fostered by learning environments. It is also known that building adaptive expertise in medical education involves putting students on a learning pathway that requires them to have, first, the motivation to innovatively problem-solve and, second, exposure to diverse content material, meaningfully presented. Including curriculum content on the health effects of climate change could help meet these two conditions for some students at least. A working definition and illustrative competencies for adaptive expertise for climate change, as well as examples of teaching and assessment approaches extrapolated from rural curricula, are provided.

The influence of prelabor rupture of the membranes on the levels of oral mucosal immunoglobulins in the neonate.

Oral mucosal immunoglobulins play an important role in the human immune system as a first-line defense against viral and bacterial infection. Secretory immunoglobulin A (sIgA), IgD and the free secretory component (FSC) can be determined in the first days of life; however, it is yet unknown which events influence the local synthesis of the immunoglobulins. The aim of this study was to evaluate the influence of prelabor rupture of the membranes (PROM) within a period of 24 h on the synthesis of oral mucosal sIgA, IgD, FSC and albumin of neonates in their first day of life. Comparison of 35 neonates with a history of PROM with a control group of 44 term neonates revealed no significant differences neither with respect to sIgA, IgD, FSC nor to albumin. The results indicate that PROM within a period of 24 h does not significantly increase the synthesis of oral mucosal immunoglobulins in neonates in the first day of life.