Chronic wounds in Australia: A systematic review of key epidemiological and clinical parameters.

Chronic wounds are a significant problem in Australia. The health care-related costs of chronic wounds in Australia are considerable, equivalent to more than AUD $3.5 billion, approximately 2% of national health care expenditure. Chronic wounds can also have a significant negative impact on the health-related quality of life of affected individuals. Studies have demonstrated that evidence-based care for chronic wounds improves clinical outcomes. Decision analytical modelling is important in confirming and applying these findings in the Australian context. Epidemiological and clinical data on chronic wounds are required to populate decision analytical models. Although epidemiological and clinical data on chronic wounds in Australia are available, these data have yet to be systematically summarised. To address these omissions and clarify the state of existing evidence, we conducted a systematic review of the literature on key epidemiological and clinical parameters of chronic wounds in Australia. A total of 90 studies were selected for inclusion. This paper presents a synthesis of the evidence on the prevalence and incidence of chronic wounds in Australia, as well as rates of infection, hospitalisation, amputation, healing, and recurrence.

Improving hospital environmental hygiene with the use of a targeted multi-modal bundle strategy.

BACKGROUND: Improving hospital environmental hygiene can reduce environmental contamination and cross-transmission risk, a precursor to healthcare associated infections (HAI). With poor cleaning practice a demonstrated problem, the process of converting evidence into practice requires investigation. The aim of this study was to assess the effectiveness of an environmental hygiene bundle in terms of changes to HAI rates, cleaning performance and environmental services workers (ESW) knowledge and attitudes. METHODS: A multi-modal bundle was designed and implemented with ESW in eight wards, in a 400-bed metropolitan teaching hospital, using a prospective, before-and-after study design. This consisted of a three-month pre-intervention phase and six-month intervention phase. This research used an implementation science framework to guide the transition from evidence into practice, with data collected in the pre-intervention phase synthesised to design the implementation strategy. RESULTS: There was no statistically significant change in infection rates in the six-month period. Significant improvements in cleaning performance were observed, with the average proportion of ultraviolet markers removed during cleaning across the wards increasing from 61.1% to 95.4%. Results also demonstrate improvements to both the knowledge and attitudes of ESW. CONCLUSION: By combining infection prevention and implementation science, this bundle was an effective way to engage environmental services staff and improve hospital cleaning.

Effect of Total Laparoscopic Hysterectomy vs Total Abdominal Hysterectomy on Disease-Free Survival Among Women With Stage I Endometrial Cancer: A Randomized Clinical Trial.

Importance: Standard treatment for endometrial cancer involves removal of the uterus, tubes, ovaries, and lymph nodes. Few randomized trials have compared disease-free survival outcomes for surgical approaches. Objective: To investigate whether total laparoscopic hysterectomy (TLH) is equivalent to total abdominal hysterectomy (TAH) in women with treatment-naive endometrial cancer. Design, Setting, and Participants: The Laparoscopic Approach to Cancer of the Endometrium (LACE) trial was a multinational, randomized equivalence trial conducted between October 7, 2005, and June 30, 2010, in which 27 surgeons from 20 tertiary gynecological cancer centers in Australia, New Zealand, and Hong Kong randomized 760 women with stage I endometrioid endometrial cancer to either TLH or TAH. Follow-up ended on March 3, 2016. Interventions: Patients were randomly assigned to undergo TAH (n = 353) or TLH (n = 407). Main Outcomes and Measures: The primary outcome was disease-free survival, which was measured as the interval between surgery and the date of first recurrence, including disease progression or the development of a new primary cancer or death assessed at 4.5 years after randomization. The prespecified equivalence margin was 7% or less. Secondary outcomes included recurrence of endometrial cancer and overall survival. Results: Patients were followed up for a median of 4.5 years. Of 760 patients who were randomized (mean age, 63 years), 679 (89%) completed the trial. At 4.5 years of follow-up, disease-free survival was 81.3% in the TAH group and 81.6% in the TLH group. The disease-free survival rate difference was 0.3% (favoring TLH; 95% CI, -5.5% to 6.1%; P = .007), meeting criteria for equivalence. There was no statistically significant between-group difference in recurrence of endometrial cancer (28/353 in TAH group [7.9%] vs 33/407 in TLH group [8.1%]; risk difference, 0.2% [95% CI, -3.7% to 4.0%]; P = .93) or in overall survival (24/353 in TAH group [6.8%] vs 30/407 in TLH group [7.4%]; risk difference, 0.6% [95% CI, -3.0% to 4.2%]; P = .76). Conclusions and Relevance: Among women with stage I endometrial cancer, the use of total abdominal hysterectomy compared with total laparoscopic hysterectomy resulted in equivalent disease-free survival at 4.5 years and no difference in overall survival. These findings support the use of laparoscopic hysterectomy for women with stage I endometrial cancer. Trial Registration: clinicaltrials.gov Identifier: NCT00096408; Australian New Zealand Clinical Trials Registry: CTRN12606000261516.

Effectiveness of the cardiac-diabetes transcare program: protocol for a randomised controlled trial.

BACKGROUND: This paper presents a protocol for a randomised controlled trial of the Cardiac-Diabetes Transcare program which is a transitional care, multi-modal self-management program for patients with acute coronary syndrome comorbid with type 2 diabetes. Prior research has indicated people hospitalised with dual cardiac and diabetes diagnoses are at an elevated risk of hospital readmissions, morbidity and mortality. The primary aim of this study is to evaluate the effectiveness (and cost-effectiveness) of a Cardiac-Diabetes Transcare intervention program on 6-month readmission rate in comparison to usual care. METHODS/DESIGN: A two-armed, randomised controlled trial with blinded outcome assessment will be conducted to evaluate the comparative effectiveness of two modes of care, including a Usual Care Group and a Cardiac-Diabetes Transcare Intervention (in addition to usual care) Group. The primary outcome is 6-month readmission rate, although a range of secondary outcomes will be collected (including self-efficacy) at baseline, 1, 3 and 6 month reassessments. The intervention group will receive in-hospital education tailored for people recovering from an acute coronary syndrome-related hospital admission who have comorbid diabetes, and they will also receive home visits and telephone follow-up by a trained Research Nurse to reinforce and facilitate disease-management-related behaviour change. Both groups will receive usual care interventions offered or referred from participating hospital facilities. A sample size of 432 participants from participating hospitals in the Australian states of Queensland and Victoria will be recruited for 90% power based on the most conservative scenarios modelled for sample size estimates. DISCUSSION: The study outlined in this protocol will provide valuable insight into the effectiveness of a transitional care intervention targeted for people admitted to hospital with cardiac-related presentations commencing in the inpatient hospital setting and transition to the home environment. The purpose of theory-based intervention comprising face-to-face sessions and telephone follow up for patients with acute coronary syndrome and type 2 diabetes is to increase self-efficacy to enhance self-management behaviours and thus improve health outcomes and reduce hospital readmissions. TRIAL REGISTRATION: This study has been registered with the Australian New Zealand Clinical Trials Registry dated 16/12/2014: ACTRN12614001317684 .

Is it worth screening elective orthopaedic patients for carriage of Staphylococcus aureus? A part-retrospective case-control study in a Scottish hospital.

BACKGROUND: With recent focus on methicillin-resistant Staphylococcus aureus (MRSA) screening, methicillin-susceptible S. aureus (MSSA) has been overlooked. MSSA infections are costly and debilitating in orthopaedic surgery. METHODS: We broadened MRSA screening to include MSSA for elective orthopaedic patients. Preoperative decolonisation was offered if appropriate. Elective and trauma patients were audited for staphylococcal infection during 2 6-month periods (A: January to June 2013 MRSA screening; B: January to June 2014 MRSA and MSSA screening). Trauma patients are not screened presurgery and provided a control. MSSA screening costs of a modelled cohort of 500 elective patients were offset by changes in number and costs of MSSA infections to demonstrate the change in total health service costs. FINDINGS: Trauma patients showed similar infection rates during both periods (p=1). In period A, 4 (1.72%) and 15 (6.47%) of 232 elective patients suffered superficial and deep MSSA infections, respectively, with 6 superficial (2%) and 1 deep (0.3%) infection among 307 elective patients during period B. For any MSSA infection, risk ratios were 0.95 (95% CI 0.41 to 2.23) for trauma and 0.28 (95% CI 0.12 to 0.65) for elective patients (period B vs period A). For deep MSSA infections, risk ratios were 0.58 (95% CI 0.20 to 1.67) for trauma and 0.05 (95% CI 0.01 to 0.36) for elective patients (p=0.011). There were 29.12 fewer deep infections in the modelled cohort of 500 patients, with a cost reduction of £831 678 for 500 patients screened. CONCLUSIONS: MSSA screening for elective orthopaedic patients may reduce the risk of deep postoperative MSSA infection with associated cost-benefits.

A randomized trial of fellowships for early career researchers finds a high reliability in funding decisions.

OBJECTIVES: Funding for early career researchers in Australia's largest medical research funding scheme is determined by a competitive peer-review process using a panel of four reviewers. The purpose of this experiment was to appraise the reliability of funding by duplicating applications that were considered by separate grant review panels. STUDY DESIGN AND METHODS: Sixty duplicate applications were considered by two independent grant review panels that were awarding funding for Australia's National Health and Medical Research Council. Panel members were blinded to which applications were included in the experiment and to whether it was the original or duplicate application. Scores were compared across panels using Bland-Altman plots to determine measures of agreement, including whether agreement would have impacted on actual funding. RESULTS: Twenty-three percent of the applicants were funded by both panels and 60 percent were not funded by both, giving an overall agreement of 83 percent [95% confidence interval (CI): 73%, 92%]. The chance-adjusted agreement was 0.75 (95% CI: 0.58, 0.92). CONCLUSION: There was a comparatively high level of agreement when compared with other types of funding schemes. Further experimental research could be used to determine if this higher agreement is due to nature of the application, the composition of the assessment panel, or the characteristics of the applicants.

Quality of life after early enteral feeding versus standard care for proven or suspected advanced epithelial ovarian cancer: Results from a randomised trial.

BACKGROUND: Malnutrition is common in patients with advanced epithelial ovarian cancer (EOC), and is associated with impaired quality of life (QoL), longer hospital stay and higher risk of treatment-related adverse events. This phase III multi-centre randomised clinical trial tested early enteral feeding versus standard care on postoperative QoL. METHODS: From 2009 to 2013, 109 patients requiring surgery for suspected advanced EOC, moderately to severely malnourished were enrolled at five sites across Queensland and randomised to intervention (n=53) or control (n=56) groups. Intervention involved intraoperative nasojejunal tube placement and enteral feeding until adequate oral intake could be maintained. Despite being randomised to intervention, 20 patients did not receive feeds (13 did not receive the feeding tube; 7 had it removed early). Control involved postoperative diet as tolerated. QoL was measured at baseline, 6weeks postoperatively and 30days after the third cycle of chemotherapy. The primary outcome measure was the difference in QoL between the intervention and the control group. Secondary endpoints included treatment-related adverse event occurrence, length of stay, postoperative services use, and nutritional status. RESULTS: Baseline characteristics were comparable between treatment groups. No significant difference in QoL was found between the groups at any time point. There was a trend towards better nutritional status in patients who received the intervention but the differences did not reach statistical significance except for the intention-to-treat analysis at 7days postoperatively (11.8 intervention vs. 13.8 control, p 0.04). CONCLUSION: Early enteral feeding did not significantly improve patients' QoL compared to standard of care but may improve nutritional status.

Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care.

BACKGROUND: Chronic leg ulcers cause long term ill-health for older adults and the condition places a significant burden on health service resources. Although evidence on effective management of the condition is available, a significant evidence-practice gap is known to exist, with many suggested reasons e.g. multiple care providers, costs of care and treatments. This study aimed to identify effective health service pathways of care which facilitated evidence-based management of chronic leg ulcers. METHODS: A sample of 70 patients presenting with a lower limb leg or foot ulcer at specialist wound clinics in Queensland, Australia were recruited for an observational study and survey. Retrospective data were collected on demographics, health, medical history, treatments, costs and health service pathways in the previous 12 months. Prospective data were collected on health service pathways, pain, functional ability, quality of life, treatments, wound healing and recurrence outcomes for 24 weeks from admission. RESULTS: Retrospective data indicated that evidence based guidelines were poorly implemented prior to admission to the study, e.g. only 31% of participants with a lower limb ulcer had an ABPI or duplex assessment in the previous 12 months. On average, participants accessed care 2-3 times/week for 17 weeks from multiple health service providers in the twelve months before admission to the study clinics. Following admission to specialist wound clinics, participants accessed care on average once per week for 12 weeks from a smaller range of providers. The median ulcer duration on admission to the study was 22 weeks (range 2-728 weeks). Following admission to wound clinics, implementation of key indicators of evidence based care increased (p < 0.001) and Kaplan-Meier survival analysis found the median time to healing was 12 weeks (95% CI 9.3-14.7). Implementation of evidence based care was significantly related to improved healing outcomes (p < 0.001). CONCLUSIONS: This study highlights the complexities involved in accessing expertise and evidence based wound care for adults with chronic leg or foot ulcers. Results demonstrate that access to wound management expertise can promote streamlined health services and evidence based wound care, leading to efficient use of health resources and improved health.

Obesity in pregnancy: outcomes and economics.

Maternal obesity is an important aspect of reproductive care. It is the commonest risk factor for maternal mortality in developed countries and is also associated with a wide spectrum of adverse pregnancy outcomes. Maternal obesity may have longer-term implications for the health of the mother and infant, which in turn will have economic implications. Efforts to prevent, manage and treat obesity in pregnancy will be costly, but may pay dividends from reduced future economic costs, and subsequent improvements to maternal and infant health. Decision-makers working in this area of health services should understand whether the problem can be reduced, at what cost; and then, what cost savings and health benefits will accrue in the future from a reduction of the problem.

Telephone counseling for physical activity and diet in primary care patients.

BACKGROUND: The delivery of effective interventions to assist patients to improve their physical activity and dietary behaviors is a challenge in the busy primary care setting. DESIGN: Cluster RCT with practices randomized to telephone counseling intervention or usual care. Data collection took place from February 2005 to November 2007, with analysis from December 2007 to April 2008. SETTING/PARTICIPANTS: Four-hundred thirty-four adult patients with type 2 diabetes or hypertension (mean age=58.2 [SD=11.8]; 61% female; mean BMI=31.1 [SD=6.8]) from a disadvantaged community were recruited from ten primary care practices. INTERVENTION: Twelve-month telephone counseling intervention. MAIN OUTCOME MEASURES: Physical activity and dietary intake were assessed by self-report at baseline, 4, and 12 months. RESULTS: At 12 months, patients in both groups increased moderate-to-vigorous physical activity by a mean of 78 minutes per week (SE=10). Significant intervention effects (telephone counseling minus usual care) were observed for: calories from total fat (decrease of 1.17%; p<0.007), energy from saturated fat (decrease of 0.97%; p<0.007), vegetable intake (increase of 0.71 servings; p<0.039), fruit intake (increase of 0.30 servings; p<0.001), and grams of fiber (increase of 2.23 g; p<0.001). CONCLUSIONS: The study targeted a challenging primary care patient sample and, using a telephone-delivered intervention, demonstrated modest improvements in diet and in physical activity. Results suggest that telephone counseling is a feasible means of delivering lifestyle intervention to primary care patients with chronic conditions-patients whose need for ongoing support for lifestyle change is often beyond the capacity of primary healthcare practitioners.

Mental health in the workplace: using the ICF to model the prospective associations between symptoms, activities, participation and environmental factors.

PURPOSE: This prospective study used the framework of ICF components to investigate the magnitude and direction of association between body functions (depression/anxiety symptoms), activity (limitations in work activities), participation (sickness absence), and environment (psychosocial aspects) in the workplace setting. METHODS: A cohort of employees completed a self-report survey at baseline and 6 months follow-up, with analysis restricted to those with at least one health condition (n = 204). Self-report measures of depression/anxiety symptoms, limitations in work activities, sickness absences, and psychosocial work environment were mapped to the corresponding ICF component. The prospective association between these components was modelled using relative risks (RR) estimated from log-binomial regression. RESULTS: Depression/anxiety symptoms were more likely to be an outcome of other ICF components, rather than a risk factor. Sickness absence, limitations in work activities, and work environment all conferred a greater than two-fold risk of depression/anxiety symptoms 6 months later. CONCLUSIONS: The ICF offers a valuable approach to understanding the contextual influences on employee mental health and work disability. Further application of the ICF framework to mental health should improve the environmental components and encourage a wider adoption of the ICF by mental health researchers and practitioners.

Competing risks models and time-dependent covariates.

New statistical models for analysing survival data in an intensive care unit context have recently been developed. Two models that offer significant advantages over standard survival analyses are competing risks models and multistate models. Wolkewitz and colleagues used a competing risks model to examine survival times for nosocomial pneumonia and mortality. Their model was able to incorporate time-dependent covariates and so examine how risk factors that changed with time affected the chances of infection or death. We briefly explain how an alternative modelling technique (using logistic regression) can more fully exploit time-dependent covariates for this type of data.

Which presenteeism measures are more sensitive to depression and anxiety?

BACKGROUND: Lost productivity from attending work when unwell, or "presenteeism", is a largely hidden cost of mental disorders in the workplace. Sensitive measures are needed for clinical and policy applications, however there is no consensus on the optimal self-report measure to use. This paper examines the sensitivity of four alternative measures of presenteeism to depression and anxiety in an Australian employed cohort. METHODS: A prospective single-group study in ten call centres examined the association of presenteeism (presenteeism days, inefficiency days, Work Limitations Questionnaire, Stanford Presenteeism Scale) with Patient Health Questionnaire depression and anxiety syndromes. RESULTS: At baseline, all presenteeism measures were sensitive to differences between those with (N=69) and without (N=363) depression/anxiety. Only the Work Limitations Questionnaire consistently showed worse productivity as depression severity increased, and sensitivity to remission and onset of depression/anxiety over the 6-month follow-up (N=231). There was some evidence of individual depressive symptoms having a differential association with different types of job demands. LIMITATIONS: The study findings may not generalise to other occupational settings with different job demands. We were unable to compare responders with non-responders at baseline due to anonymity. CONCLUSIONS: In this community sample the Work Limitations Questionnaire offered additional sensitivity to depression severity, change over time, and individual symptoms. The comprehensive assessment of work performance offers significant advantages in demonstrating both the individual and economic burden of common mental disorders, and the potential gains from early intervention and treatment.

A cost-effectiveness analysis of two rehabilitation support services for women with breast cancer.

The purpose of this research was to estimate the cost-effectiveness of two rehabilitation interventions for breast cancer survivors, each compared to a population-based, non-intervention group (n = 208). The two services included an early home-based physiotherapy intervention (DAART, n = 36) and a group-based exercise and psychosocial intervention (STRETCH, n = 31). A societal perspective was taken and costs were included as those incurred by the health care system, the survivors and community. Health outcomes included: (a) 'rehabilitated cases' based on changes in health-related quality of life between 6 and 12 months post-diagnosis, using the Functional Assessment of Cancer Therapy-Breast Cancer plus Arm Morbidity (FACT-B+4) questionnaire, and (b) quality-adjusted life years (QALYs) using utility scores from the Subjective Health Estimation (SHE) scale. Data were collected using self-reported questionnaires, medical records and program budgets. A Monte-Carlo modelling approach was used to test for uncertainty in cost and outcome estimates. The proportion of rehabilitated cases was similar across the three groups. From a societal perspective compared with the non-intervention group, the DAART intervention appeared to be the most efficient option with an incremental cost of $1344 per QALY gained, whereas the incremental cost per QALY gained from the STRETCH program was $14,478. Both DAART and STRETCH are low-cost, low-technological health promoting programs representing excellent public health investments.